AETC SPECIAL DUTY APPLICATION

AUTHORITY: 10 U.S.C. 8012 AND EO 9397. PRINCIPAL PURPOSE: For application and certification of special duty assignment. ROUTINE USES: Used to apply for MAJCOM controlled special duty assignment. The SSAN is used for certification of the individual and records. DISCLOSURE IS VOLUNTARY: Failure to provide the information and SSAN could preclude selection to special duty assignment. Application for: Military Training Instructor (MTI)

Part I. General Information (To be completed by the applicant)

Name (Last, First, M.I.)

Grade

SSAN

Date of Birth

Date of Rank (DD/MM/YYYY)

CONTROL AFSC

PRIMARY AFSC

TOS (MM/YY)

DEROS (if applicable)

Desired RNLTD

Are you currently in Phase 1 or 2 (circle one) of the Involuntary Retraining Program? Yes No

Do you currently have an assignment action pending? Yes No

Date Entered Air Force (MM/YY)

Base and Unit to which you are Currently Assigned:

Email Address

Supervisor’s Name and DSN Duty Phone

DSN Duty Phone

Marital Status M S D

Spouse in service Yes No

Number of DEPNS

Single Parent Yes No

Highest Level PME

General AQE Score

Level of Education

Any prior special duty assignments? If yes, indicate type, when, and where Yes No

Why would you like to be an MTI?

If applicable, do you have an approved Career Job Reservation (CJR)? Yes No N/A Your Hometown Spouse’s Hometown

Are you currently receiving a Selective Reenlistment Bonus or Initial Enlistment Bonus? Yes No

I understand the conditions pertaining to this application and attest to the following remarks. I certify my legal dependents and I are in good health and have no medical history of psychiatric problems or any physical or mental ailments that would require specialized treatment. If there is a history of any of the above issues, I must immediately submit the appropriate documentation for consideration. I understand that my withholding or misrepresentation of the requested information could result in disciplinary action under the UCMJ. I fully understand I am applying for an AETC Special Duty and that this application may be used for assignment action.

Date

Signature of Applicant

Part II. Quality Force Issues (To be completed by your Commander or First Sergeant ONLY)

Is the applicant enrolled In mandatory fitness program Yes No

Is the applicant currently on a UIF/Control Roster Yes No

EPR Ratings: (Begin with the most current rating in Block 1 and work back) (Attach copies of the applicant’s last three EPRs to this application)

1.

2.

3.

4.

5.

Is the applicant under investigation or does the applicant or any family member(s) have any military or civilian judicial actions pending? Yes No

Is the applicant currently serving a controlled tour? (If yes please provide the date that tour expires) Yes No

Does the applicant speak clearly and distinctly? Yes No

How would you rate the applicant’s military image? Outstanding Excellent Good Fair Poor

Any medical history of back, feet, legs, or throat problems? Yes No

Part III. Commander and First Sergeant Endorsement

I recognize that it is not in the best interest of the Air Force to have confirmed perpetrators of sexual harassment performing AETC special duties. I have reviewed the above individual’s records and they do not reflect any information, which in my judgment would preclude his/her selection for an AETC Special Duty Assignment. I have personally interviewed the applicant and to my knowledge, member is emotionally stable, morally sound, and financially responsible. I find the member fully qualified for this AETC Special Duty Assignment. If I have non-recommended the applicant for recruiting duty I have justified my non-recommendation in the Commander Comments section below or in an attached Official Memorandum.

Unit CC initial appropriate box

RECOMMEND

DO NOT RECOMMEND

1st Sgt Signature and Signature Block

Date

Sq/CC Signature and Signature Block

Date

Commander’s Comments:

AUTHORITY: 10 U.S.C. 8012 AND EO 9397. PRINCIPAL PURPOSE: For application and certification of special duty assignment. ROUTINE USES: Used to apply for MAJCOM controlled special duty assignment. The SSAN is used for certification of the individual and records. DISCLOSURE IS VOLUNTARY: Failure to provide the information and SSAN could preclude selection to special duty assignment.

Part IV. Medical information for all applicants (To be completed by Unit Fitness Monitor/Life Skills/Dental/MTF)

I consent to disclosure of all requested information below.

Applicant’s Printed Name

Applicant’s Signature

Date

MEMORANDUM FOR UNIT FITNESS MONITOR, DENTAL CLINIC, AND HOST MEDICAL TREATMENT FACILITY FROM: 737 TRSS/TSRR 1618 Truemper St. Suite 155 Lackland AFB, TX 78236 SUBJECT: Fitness/Dental/Medical Records Review 1. Request you screen the Medical, and Dental record of_______________________________________________ (Rank, Name, and SSAN) 2. Any indication of physical medical problems (especially a history of back, feet, leg, or throat problems), psychiatric problems (to include a history of drug or alcohol abuse), involvement with the Air Force Family Advocacy, or EFMP program, or civilian agencies relating to child or spouse abuse requires documentation from the applicant’s medical provider to be attached to this application in the form of an Official Memorandum or documented in Section VI of this application. //SIGNED// STEVEN E. SCHIELE, SMSgt, USAF Deputy Chief, AETC Assignments SECTION A: Fitness Standard Review (To be completed by the Unit Fitness Monitor) CURRENT HEIGHT: ________ CURRENT WEIGHT: ________ FITNESS TEST: Pass Fail (check one) ABDOMINAL CIRCUMFERENCE: ________ FITNESS SCORE: ________ DATE OF TEST:_____________ ______________________________________________ ____________________________________ Unit Fitness Monitor Signature Date Printed Name, Rank, Duty Title SECTION C: Dental Records Review (To be completed by a Dental Records Representative Only) A dental records review of the member listed above has been accomplished and their current Dental Classification is: I II III IV (circle one) (Please document reason for Dental Classification Codes III or IV in Section V of this application) _______________________________________________ __________________________________ Dental Record Reviewer’s Signature Date Printed Name, Rank, Duty Title SECTION D: Medical Records Review (To be completed by the Public Health Section or PCM at the Medical Treatment Facility) NOTE: The applicant does not require a physical examination, only a review of their current physical profile. The medical records of the applicant listed above have been reviewed with the following results: The applicant’s physical profile is: P____ U____ L____ H____ E____ S____ (If profile is less than 121221 attach an AF Form 422 documenting the applicant’s medical problem that is causing the current profile) _____________________________________ ______________ ____________________________________________ Medical Reviewer’s Signature Date Printed Name, Rank, Duty Title Medical Remarks (All comments made in this section include the date, signature, printed name, rank, and duty title of the person making the remarks. However, the preferred method of submission for documentation of any medical problem that would adversely affect the applicant’s ability to perform MTI duty would be an Official Memorandum attached to this application.