Form NAVCRUIT 1130/104 NAVCRUIT 1130/104 United States Navy Tattoo Screening Certificate

United States Navy Tattoo Screening Certificate
NAVCRUIT 1130/104 (Rev. 08-2019)

OMB CONTROL NUMBER: 0703-0029
OMB EXPIRATION DATE: XX/XX/XXXX
Supporting Directive COMNAVCRUITCOMINST 1130.8K and 1131.2G

PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations, 10 U.S.C. Sections governing authority to appoint officers; 10 U.S C. 591, 600, 716, 2107,
2122, 5579, 5600; Merchant Marine Act of 1939 (as amended); and E.O.s 9397, 10450, and 11652
PRINCIPAL PURPOSES: To manage and contribute to the recruitment of qualified men and women for officer programs and the regular and reserve
components of the Navy. To ensure quality military recruitment and to maintain records pertaining to the applicant's personal profile for purposes of
evaluation for fitness for commissioned service.
ROUTINE USE(S): In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information
contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
To the Department of Transportation in the performance of their official duties relating to the recruitment of Merchant Marine personnel, to
the Veterans Administration and Selective Service Administration in the performance of their official duties related to enlistment and
reenlistment eligibility and related benefits, and to other departments and agencies of the Executive Branch of government in the
performance of their official duties related to the management of quality military recruitment as published in the Federal Register.
DISCLOSURE: Disclosure is voluntary, however, without this information, your entry into the Navy Reserve Officer - Special Duty Public Affairs (1655)
program may not be accomplished. A social security number is necessary to make positive identification of the individual and to permit this service
agreement to become part of the official service record.
________________________________________________________________________________________________________________________
Agency Disclosure Notice
The public reporting burden for this collection of information, OMB 0703-0029 is estimated to average 1.5 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control
number.

NAME (Last, First, Middle, Jr., etc.)

Date:
YES

NO

N/A

1. Does the applicant/candidate have any tattoos/body art/branding?
2. Does the applicant/candidate have any tattoo/body art/brand visible behind the ears or on the neck?
3. Has the applicant/candidate ever had any tattoo/body art/brand removed or covered?

Any "Yes" response above requires an enlistment eligibility determination by the NAVCRUITDIST CO (May be delegated to
XO, R-OPS, CMC, CR, or EPDS when authorized "by direction" authority by the CO).

YES

NO

N/A

4. Are any of the tattoos/body art/brands on the face (excluding cosmetic tattoos) or scalp?
5. Is there one or more tattoos larger than one inch on the neck or behind the ears, visible above the collar
of a properly fitted crew neck t-shirt? (Excluding cosmetic tattoos)
6. If applicable, are cosmetic tattoos applied in good taste with natural color enhancement and of a
conservative nature?
7. Are any of the tattoos/body art/branding representative of gang membership, advocate racial, ethnic,
racial discrimination, sexism (including expressions of nudity), drug related, obscene, or are prejudicial to
good order, discipline, and morale, or are of a nature to bring discredit upon the Navy?
8. Are any of the tattoos a result of a specific activity? (i.e., specifically an illegal activity or as a result of any
violation of law (s))

Any "Yes" response to items 4, 5, 7, or 8 above is disqualifying, not authorized for Enlistment. Any "No" response to Item 6
is disqualifying, not authorized for Enlistment.
NOTE: All questionable body markings, due to content, size, number, and/or location, shall be forwarded to NAVCRUITCOM for
eligibility determination.

Applicant Signature

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Date
FOR OFFICIAL USE ONLY
PRIVACY SENSITIVE

Recruiter Signature

Date

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United States Navy Tattoo Screening Certificate
NAVCRUIT 1130/104 (Rev. 08-2019)

OMB CONTROL NUMBER: 0703-0029
OMB EXPIRATION DATE: XX/XX/XXXX
Supporting Directive COMNAVCRUITCOMINST 1130.8K and 1131.2G

Describe all tattoos, brands, and/or body ornamentation (if applicable) on following page.

Explain tattoo, brand, and body ornamentation removal process, if applicable.

CO/XO/R-OPS/CMC/CR/EPDS Reviewing Comments:

APPROVED

DISAPPROVED

CO/XO/R-OPS/CMC/CR/EPDS Signature

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Typed Name and Title:

FOR OFFICIAL USE ONLY
PRIVACY SENSITIVE

Date:

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United States Navy Tattoo Screening Certificate
NAVCRUIT 1130/104 (Rev. 08-2019)

OMB CONTROL NUMBER: 0703-0029
OMB EXPIRATION DATE: XX/XX/XXXX
Supporting Directive COMNAVCRUITCOMINST 1130.8K and 1131.2G

Documentation. The following depicts the location and description of the applicant's body markings. Place number on body location
and describe in corresponding blocks below indicating content and size in inches (not required if no Tattoos):

FRONT VIEW

BACK VIEW

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

6.

6.

7.

7.

8.

8.

9.

9.

10.

10.

Certification. I certify above body marking information is accurate.
(Name of Applicant)

(Name of Recruiting Rep)

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(Signature of Applicant)

(Signature of Recruiting Rep)
FOR OFFICIAL USE ONLY
PRIVACY SENSITIVE

(Date)

(Date)

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