VOLUNTARY ADOS Checklist Version 8

APPLICANT SIGNATURE: ____________________________________

VOLUNTARY ADOS Checklist Version 8 POC: JFHQ-G3 (717) 861-6846

T32 ADOS CHECKLIST

NAME: DATE:

UNIT:

UNIT/ORGANIZATION WHERE ADOS WILL BE PERFORMED:

ADOS DUTY POSITION:

STATEMENT OF NEED:

PAARNG Application for Active Duty Operational Support (ADOS) Form

Block 22 Signed by Records Custodian

Block 24 Signed by Applicant

Block 33 Signed by Unit Commander and Records Custodian

Current NGB Form 23A, within 30 days of application date

Verification of security clearance memorandum from the State Security Manager, within 30 days of application date

DA Form 705 (Army Physical Fitness Test Scorecard) with Record-Go APFT score, within 60 days of application date.

DA 5500 or 5501 (Body Fat Content Worksheet), within 6 months of application start date

Waiver (1095/17 Years/Sanctuary/Separation Pay)

Pregnancy test results (Females Only), within 15 days of start date

HIV test, within last 2 years of start date

Do you agree to voluntarily attend IDT and AT periods?

Are you an Employee of the Commonwealth of Pennsylvania?

Are you a Pennsylvania National Guard Technician?

No Yes or

No Yes or

Yes or No

Current Individual Medical Readiness (IMR) Record indicating Periodic Health Assessment (PHA), within one year of start date Soldier Record Brief (SRB)

VOLUNTARY ADOS Checklist Version 8

VOLUNTARY ADOS Checklist Version 8 POC: JFHQ-G3 (717) 861-6846

T10 ADOS CHECKLIST (for T10 tours, complete in addition to T32 ADOS checklist)

DA Form 1506 (Statement of Service), covering all active service over the last four years

DD Form 2648-1 (Pre-separation Counseling Checklist)

DD Form 2958 (Service Member Career Readiness Standards/Individual Transition Plan Checklist)

PAARNG ADOS Form 1

_________

DATA REQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY: ̀

PRINCIPLE PURPOSE:

32 USC 502

To determine eligibility and schedule individuals for active duty operational support (ADOS)

ROUTINE USES: To identify the applicant as a Reserve Component member and to issue active duty operational support orders.

DISCLOSURE: Completing this form is mandatory for individuals applying for active duty operational support. If not completed, applicant will not be eligible for the requested tour.

PART I - APPLICANT

1. TO

2. NAME (Last, First, MI) 3. SSN

4a. PERMANENT HOME ADDRESS (Include ZIP code) 5a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (if different from permanent home address) (include ZIP code)

4b. HOME TELEPHONE NUMBER (Include area code) 5b. HOME TELEPHONE NUMBER (Include area code)

4c. BUSINESS TELEPHONE NUMBER (Include area code) 5c. BUSINESS TELEPHONE NUMBER (Include area code)

6. UNIT OF ASSIGNMENT OR ATTACHMENT 7. GRADE 8. BRANCH/MOS

9. SEX 10. D.O.B. 11. MARITAL STATUS 12. NO. OF DEPENDANTSM F

13. PRIMARY SSI (AOC)/MOS 14. DUTY SSI (AOC)/MOS 15. HEIGHT 16. WEIGHT

17. drawing a pension, disability 18. TOTAL AD PointsI am I am not compensation, or retired pay

from the U.S. Government

19. SIGNATURE OF JFHQ HUMAN RESOURCE OFFICER VERIFYING ADMIN DATA IN BLOCK 18

20. DATES OF ADOS REQUESTED:

a. FIRST CHOICE b. SECOND CHOICE

NUMBER OF DAYS BEGINNING DATE/TIME NUMBER OF DAYS BEGINNING DATE/TIME

LOCATION LOCATION

DUTY/TRAINING AGENCY DUTY/TRAINING AGENCY

21. To the best of my knowledge and belief, I am physically qualified for active military service. I was:

a. LAST EXAMINED ON b. LOCATION

22. SIGNATURE OF COMPANY RECORDS CUSTODIAN 23. DATE

PAARNG ADOS Form 2

24. REMARKS

"I understand that, although at the completion of my tour, I may be within 2 years of qualifying for an active duty retirement under 10 USC 1293, 3911, or 3914, it is current Army policy that I will be released from ADOS at the completion of my tour unless I am offered a follow-on tour as approved by CNGB. I hereby waive sanctuary and consent to being ordered to ADOS for a period indicated on my order and consent to my release from ADOS at the completion of this tour."

______________________________________________________ (Signature of applicant)

(THIS ACTION WILL NOT BE APPROVED WITHOUT THE SOLDIER’S SIGNATURE IN THIS BLOCK) ____________________________________________________________________________________________________________________

ADDITIONAL REMARKS:

■ Identify Break In Service. (Used to compute / verify days elapsed since last active duty operational support tour (31-Day Break))

♦ (a) Date of the last day on ADOS status: .. ♦ (b) Date new tour of duty to start:

♦ Number of Days (subtract b from a):

PART II - RECORDS CUSTODIAN

25. PAY ENTRY BASIC DATE 26. SECURITY CLEARANCE 27. DATE OF RANK

28. RYE DATE 29. ETS (Enlisted) 30. MANDATORY REMOVAL DATE (Officers)

31. HIV TEST DATE32. PANOGRAPHIC DENTAL X-RAY ON FILE YES NO

33. Preceding Duty: List all AD performed within the past 4 years. NGB FORM 23A must be attached IF number of points exceed 730 days.

a. PERIOD OF PRECEDING DUTY b. TYPE OF AD c. LOCATION d. DUTY(B1 or B4 on NGB 23B) INSTALLATION PERFORMED

FROM TO NO. AD PTS

SIGNATURE OF COMPANY COMMANDER OR SIGNATURE AUTH DATE GRADE TITLE

SIGNATURE OF COMPANY RECORDS CUSTODIAN DATE GRADE TITLE

NAME, SIGNATURE AND TELEPHONE NUMBER OF STATE ADOS APPROVING AUTHORITY (Approving official check appropriate box)

THIS TOUR APPLICATION IS APPROVED

THIS TOUR APPLICATION IS NOT DATE GRADE APPROVED

NAME AND OFFICE OF POC COMMERCIAL AND DSN TELEPHONE

PAARNG ADOS Form 3