Air Force Recruiting Information Support System - Total Forces (AFRISS-TF)

BRIEFING ITEMS

PROCESSING PROGRAMS
Program

Subprogram

Health Professional

DEMOGRAPHICS
Lead Date
Prefix

Briefed on the Privacy Act

Specialty

Medical Corps HP Scholarship Program

DD Form 2644

Lead Origination

Lead Source

Recruiter Generated

Military

20121115

Middle Name (if none enter NMN)
NMN

First Name
Ymcyu

Registered to Vote & ST
DD Form 2645
Gender

Last Name
Hbento

Verified SSN
863-36-3985

Suffix DOB

Age

Maiden Name / Alias Names
Citizenship

Racial Category
Eye Color Other

Hair Color

Ethnic Category

Religious Preference

1st Foreign Language None

2nd Foreign Language None

Selective Service Number
Home Phone 6074268785
Current Address

Cell Phone

Work Phone

342 Qshe Oiiafp Fsynrq Houston GA 49801 US

Home of Record
Personal Email
Valid Drivers License

Business Email

Present Occupation

Drivers License #

State

EXP Date

BIRTH VERIFICATION
City of Birth

County

Naturalization #

INS # (Citizen Certificate)

INTERVIEW

State

Country

Alien Registration #

CCMAPPEDDS
Y

REMARKS

Verification

N

Y

Citizenship

Prior Service

Conscientious Objector
Morals

Education
Dependents

Age

Drugs

Physical

SSN

Domestic Violence

Waiver(s) Required

N

Ymcyu NMN Hbento - 863-36-3985

Height/Weight History
Name: Ymcyu NMN Hbento
MEPS Height:
Open Data

SSN: 863-36-3985

Gender:

MEPS Weight:
Height (in)

Weight (lbs)

Min. Weight

Max. Weight

BFM

Remarks

Ymcyu NMN Hbento - 863-36-3985

MARITAL STATUS
Marital Status

What document did you use to verify the Marital Status?

MILITARY SPOUSE
Spouse's SSN:
Spouse's paygrade:
Spouse's branch of service:
Spouse's current duty station:
Is military spouse the step-parent of any children in the applicant's custody?

DEPENDENTS
Number of Adult Dependents

Number of Minor Dependents

Expected Marital and/or Dependency Changes
What document did you use to verify the Single Signature Parental Consent?

RELATIVES (Check the relatives which are dependents)
LAST NAME

FIRST NAME

ADDRESS

LAST NAME

CITY

FIRST NAME

ADDRESS

LAST NAME

FIRST NAME

LAST NAME

FIRST NAME

LAST NAME

FIRST NAME

LAST NAME

FIRST NAME

LAST NAME

ADDRESS

STATE

STATE

STATE

FIRST NAME

STATE

ZIP

FIRST NAME

STATE

ZIP

STATE

DEPENDENT

COUNTRY

DEPENDENT

COUNTRY

DEPENDENT

RELATIONSHIP

ZIP

COUNTRY

DEPENDENT

RELATIONSHIP

ZIP

COUNTRY

DEPENDENT

RELATIONSHIP

ZIP

MIDDLE NAME

CITY

COUNTRY

RELATIONSHIP

MIDDLE NAME

CITY

DEPENDENT

RELATIONSHIP

MIDDLE NAME

CITY

ADDRESS

ZIP

MIDDLE NAME

CITY

ADDRESS

STATE

COUNTRY

RELATIONSHIP

MIDDLE NAME

CITY

ADDRESS

ZIP

MIDDLE NAME

CITY

ADDRESS

STATE

RELATIONSHIP

MIDDLE NAME

CITY

ADDRESS

LAST NAME

MIDDLE NAME

COUNTRY

DEPENDENT

RELATIONSHIP

ZIP

COUNTRY

DEPENDENT

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

DATE OF BIRTH

CUSTODY

SELFCARE

Ymcyu NMN Hbento - 863-36-3985

The applicant has been shown the following films:
Aptitude Index Film
BMTS Film
CCT/PJ Film
COT Film
MEPS Processing
Film
OTS/COT Film
Security Forces Film
EOD Film
Peace Keepers Film

ALTERNATE EMAILS
Type

ALTERNATE PHONES
Email

Type

Email

Ymcyu NMN Hbento - 863-36-3985

MORALS
Date

Morals
Cat. Violation or Charge

Reduced
Charge

Released on

Place/City

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Released on

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Reduced
Charge

Possible Max Sentence

Final or Current
Disposition / Remarks

Court
Validation type

Possible Max Sentence

State

Court Type

Adjudication
Disposition

UCMJ

Ymcyu NMN Hbento - 863-36-3985

Financial Record
In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
Date Filed

Amount

Bankruptcy Type

Docket/Account

Name of the court involved

Have you ever experienced financial problems due to gambling?
From Date

To Date

Amount

Descriptions

In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?
Year

Type

Amount

Reason

In the past seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement for travel or
credit card provided by your employer?
Date

Name

Amount

Reason

Other than previously listed, have any of the following happened to you?
-In the past seven (7) years, you have been delinquent on alimony or child support payments.
-In the past seven (7) years, you had a judgement entered against you. (Include financial obligations for which you were the
sole debtor, as well as those for which you were a cosigner or guarantor).
-In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include
financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).
-You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as
those for which you are a cosigner or guarantor).
Date Began

Debt Owed To

Account Number

Amount

Reason

Other than previously listed, have any of the following happened?
-In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed?
(Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)
-In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor)
-In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which
you were the sole debtor, as well as those for which you were a cosigner or guarantor)
-In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as
agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or
guarantor)
-In the past seven (7) years, you were evicted for non-payment?
-In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason?
-In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial
obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)
-You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as
well as those for which you are a cosigner or guarantor)

Date Began

Debt Owed To

Account Number

Amount

Reason

Ymcyu NMN Hbento - 863-36-3985

EDUCATION
Grade Relevance

Major Code Major
School Type

Degree Type

Degree Type

Grade Relevance

Degree Type

Major Code Major
School Type

Accredited From

Degree Type

Highest Education Year Completed
Education Level

State

Zip

State

Zip

Tier

Country

No. Yrs Comp Graduated Qual Degree

Accredited From

City

To

State

Zip

Tier

Country

No. Yrs Comp Graduated Qual Degree

Tier

Total Quality Points Total Credit Hours Total Semester Hrs
Apt

Address

City

Total College Semester Hours

State

Zip

MEPCOM
Education Level

Medical Specialty

Y

Country

Total College Quarter Hours

What paramilitary organizations (JROTC/CAP/Scouts) has the lead participated with?
Degree/Residency

Country

No. Yrs Comp Graduated Qual Degree

City

To

Apt

Other Major

Degree Title

Tier

Total Quality Points Total Credit Hours Total Semester Hrs

Address

Name of School

City

To

Apt

Other Major

Degree Title

No. Yrs Comp Graduated Qual Degree

Total Quality Points Total Credit Hours Total Semester Hrs

Address

Name of School

Major Code Major
School Type

Accredited From

Other Major

Degree Title

Grade Relevance

Apt

Address

Name of School

Major Code Major

To

Total Quality Points Total Credit Hours Total Semester Hrs

Other Major

Degree Title

Grade Relevance

School Type

Accredited From

Name of School

Award Type

N

Civil Air Patrol

Yr Awarded

Scout Award

Yr Awarded

JROTC
ROTC

MEDICAL OFFICER CREDENTIALS
Licensed

Certified

Registered

Board Certified

Ymcyu NMN Hbento - 863-36-3985

AFOQT
Form/Version

Date Tested

Pilot

Nav

AA

Verbal

Quantitative

Other Tests
Type

Date

Version

Score

GRE

ASVAB
Test
Date

Version

QT

M

A

G

E

Test Location

GS AR WK PC MK

EI

AS MC AO

VE

NO CS

Validation
Date

Other Tests
Date

Specialty

Pull-Ups

Count

Push-Ups

Count

Date

Count

Push-Ups

Count

Pull-Ups

Count
Count

Count

Push-Ups

Count

Overall
Surface Swim
Run

Type
Sit-Ups

Count

Underwater Swim 1
Underwater Swim 2

Sit-Ups

Count

Underwater Swim 1
Underwater Swim 2

Run

Count

Underwater Swim 1
Underwater Swim 2

Sec

Min

Sec

Min

Sec

Min

Sec

Overall
Surface Swim
Run

Type
Sit-Ups

Min

Overall
Surface Swim

Type

Specialty

Pull-Ups

Underwater Swim 1
Underwater Swim 2

Specialty

Push-Ups

Date

Count

Specialty

Pull-Ups

Date

Type
Sit-Ups

Min

Sec

Min

Sec

Overall
Surface Swim
Run

Min

Sec

Min

Sec

Ymcyu NMN Hbento - 863-36-3985

PRIOR SERVICE
Start

End

Branch

State

Grade

RE

SPD/SPN

Character of Service

AFSC/MOS

Job Title

Grade
Relevance

Conditional Release (DD Form 368) required and submitted.
Date Initiated 368 Date Received 368

DD Form 368 sent to Unit Name

Date Forwarded
368
Address

Unit Phone #

City

State

Zip Code

Ymcyu NMN Hbento - 863-36-3985

DRUGS
Type of Drug

First Used

Last Used

Age at Use

How Drug Was Used & Frequency of Use

Times Used

Ymcyu NMN Hbento - 863-36-3985

Accessions Interview
What AFSC is the applicant enlisting / training into? (DAFSC)
Is this a Critical AFSC?
Is member fully qualified for the AFSC?
What PAS Code / Unit will the applicant be accessing into?
What Position number will the applicant be placed into?
Enter Date of Appointment
Enter Date of Enlistment
Enter Enlistment Pay Grade
Did applicant attend the Air Force Academy?

Ymcyu NMN Hbento - 863-36-3985

Physical Data
Source (TOSIP, DD FORM 2807-1)
Physical Date

Physical Type

Physical Location
Physical Height
P

U

Specify if Other
Specify if Other

Location Type
Physical Weight

L

H

E

S

X

BFM%

Uncorrected distant vision for left eye 20/

right eye 20/

Corrected distant vision for left eye 20/

right eye 20/

Uncorrected near vision for left eye 20/

right eye 20/

Corrected near vision for left eye 20/

right eye 20/

Is vision corrected with glasses, or contacts?

Color Vision Passed?

Does the applicant have unrestricted use of all fingers on both hands?
Does the applicant have a speech impediment?

Depth Perception Passed?

Explain

Drug Use

Does the applicant have a fear of heights?

Explain

Source (TOSIP, DD FORM 2807-1)
Physical Date

Physical Type

Physical Location
Physical Height
P

U

Specify if Other
Specify if Other

Location Type
Physical Weight

L

H

E

S

X

BFM%

Uncorrected distant vision for left eye 20/

right eye 20/

Corrected distant vision for left eye 20/

right eye 20/

Uncorrected near vision for left eye 20/

right eye 20/

Corrected near vision for left eye 20/

right eye 20/

Is vision corrected with glasses, or contacts?

Color Vision Passed?

Does the applicant have unrestricted use of all fingers on both hands?
Does the applicant have a speech impediment?

Depth Perception Passed?

Explain

Drug Use

Does the applicant have a fear of heights?

Explain

Source (TOSIP, DD FORM 2807-1)
Physical Date

Physical Type

Physical Location
Physical Height
P

U

Specify if Other
Specify if Other

Location Type
Physical Weight

L

H

E

S

X

BFM%

Uncorrected distant vision for left eye 20/

right eye 20/

Corrected distant vision for left eye 20/

right eye 20/

Uncorrected near vision for left eye 20/

right eye 20/

Corrected near vision for left eye 20/

right eye 20/

Is vision corrected with glasses, or contacts?

Color Vision Passed?

Does the applicant have unrestricted use of all fingers on both hands?
Does the applicant have a speech impediment?

Depth Perception Passed?

Explain

Drug Use

Does the applicant have a fear of heights?

Explain

Source (TOSIP, DD FORM 2807-1)
Physical Date

Physical Type

Physical Location
Physical Height
P

U

Specify if Other
Specify if Other

Location Type
Physical Weight

L

H

E

S

X

BFM%

Uncorrected distant vision for left eye 20/

right eye 20/

Corrected distant vision for left eye 20/

right eye 20/

Uncorrected near vision for left eye 20/

right eye 20/

Corrected near vision for left eye 20/

right eye 20/

Is vision corrected with glasses, or contacts?

Color Vision Passed?

Does the applicant have unrestricted use of all fingers on both hands?
Does the applicant have a speech impediment?

Depth Perception Passed?

Explain

Drug Use

Does the applicant have a fear of heights?

Explain

Source (TOSIP, DD FORM 2807-1)
Physical Date

Physical Type

Physical Location
Physical Height
P

U

Specify if Other
Specify if Other

Location Type
Physical Weight

L

H

E

S

X

BFM%

Uncorrected distant vision for left eye 20/

right eye 20/

Corrected distant vision for left eye 20/

right eye 20/

Uncorrected near vision for left eye 20/

right eye 20/

Corrected near vision for left eye 20/

right eye 20/

Is vision corrected with glasses, or contacts?

Color Vision Passed?

Does the applicant have unrestricted use of all fingers on both hands?
Does the applicant have a speech impediment?

Depth Perception Passed?

Explain

Does the applicant have a fear of heights?

Drug Use
Explain

Ymcyu NMN Hbento - 863-36-3985

MAIDEN NAME / ALIAS NAMES

Enter maiden name and alias names used. Mark checkbox if maiden name. Include from and to dates.

Maiden

First Name

Middle Name Last Name

Suffix

From Date To Date

Reason

Other

Maiden

First Name

Middle Name Last Name

Suffix

From Date To Date

Reason

Other

Maiden

First Name

Middle Name Last Name

Suffix

From Date To Date

Reason

Other

Maiden

First Name

Middle Name Last Name

Suffix

From Date To Date

Reason

Other

Ymcyu NMN Hbento - 863-36-3985

PROGRAM JOB CHOICES
Commissioning/DEP Grade

EAD Grade

Date Available for Training

Proposed EAD Date

Bonus AFSC Qualified Y

Incentive

HPSPA Alternate Number

Remarks

AFSC PREFERENCES
1st AFSC Choice
2nd AFSC Choice
3rd AFSC Choice
4th AFSC Choice
5th AFSC Choice
6th AFSC Choice
7th AFSC Choice
8th AFSC Choice
9th AFSC Choice
10th AFSC Choice

LOCATION PREFERENCES
CONUS Preferences

OVERSEAS Preferences

First

First

Second

Second

Third

Third

Fourth

Fourth

Fifth

Fifth

Sixth

Sixth

Seventh

Seventh

Board Selected AFSC
AFSC

Assignment Reservation Data
Class Number
Assignment Type
MPF Processing
Assignment Credit

Class Date

Ymcyu NMN Hbento - 863-36-3985

Recruiter

COURSES
Algebra

Geometry

Physics

Trigonometry

Biology

Chemistry

Typing

English Composition

Computer

English

Mathematics

General Science

OTHER JOB QUALIFIERS
SJC Code
Does the applicant have a fear of insects or Spiders?
Does the applicant have a fear of blood?
Does the applicant have a fear of guns?
Does the applicant have a fear of fire?
Does the applicant have a history of emotional instability?
Does the applicant have a history of conviction for embezzlement?
Does the applicant have a history of confinement?
Does the applicant have a history of claustrophobia?
Does the applicant speak distinct English?
Have you ever been in the Peace Corps?
Does the applicant have a history of Temporomanibular Joint Disorder
(TMJ), jaw locking or jaw pain?
Have you ever been convicted of a crime of domestic violence?

Whiteley, FB NMN -