Are you Qualified?

Full Name:

College/University:

Major:

Projected Graduation Date:

Are you currently enrolled full-time (12 or more credits)?:

Last Semester's GPA:

Cumulative GPA:

SAT/ACT scores:

Are you a US Citizen?:

Current Address:

Phone at above address:

Cell phone:

Best time to call:

Alternate e-mail:

Home Address:

Phone at home address:

Date of Birth:

Place of birth (City and State):

Height:

Weight:

Do you have 20/20 vision? If not, what is it and are you correctable to 20/20?:

Are you color blind or color deficient?:

Do you have any other vision problems or have you had eye surgery?

Has a doctor ever diagnosed you with asthma? If yes, were you ever prescribed an inhaler? If yes, when is that last time you used an inhaler?:

Has a doctor ever prescribed an inhaler for anything other than asthma?

Have you ever been diagnosed by a doctor with any allergies? If yes, what are you allergic too?:

Are you currently taking any prescribed medications? If yes, what are they and for what reason are you taking them?:

If not, have you ever taken any prescribed medication in the past for anything other than illness/flu?:

Have you ever taken any medication to improve/alter your mood (Ritalin, Wellbutrin, Straterra, Zoloft, Prozac, or anything similar)? If yes, what and for what reason?:

Any known diseases or illness in your medical history? If yes, what are they?:

Have you ever been hospitalized overnight? If yes, for what?:

Have you ever had surgery? If yes, what for and when?:

Do you have any pins, plates, screws, rods, or metal permanently placed in your body? If yes, what and where?

Have you ever seen a doctor for any reason other than minor conditions or routine physicals? If yes, for what?

Have you ever seen a counselor, psychiatrist or psychologist? If yes, for what?

Were you prescribed any medication? If yes, what was it and how long did you take it?

Do you currently wear braces? If yes, when will they be removed?

Do you have any tattoos? If yes, how many, what are they, where are they located?

Have you ever had any tattoos removed?

Do you currently have any body piercings, other than your ears (if female)? If yes, what and where?

Have you ever had a traffic citation (speeding, parking, moving violation, red light), since you have had your driver's license? If yes, what for and when?

Have you ever had your driver's license suspended or taken away by authorities? If yes, for what?

Have you ever been arrested or charged with a crime, as an adult or juvenile? (Even if you were told that the record was sealed) If yes, what for and when?

Have you ever tried marijuana? If yes, how many times/when was the last time?

Have you ever used any other illegal drugs? If yes, which drugs have you used and when was the last time?

What is your current marital status?

Do you have any children? If yes, how many?

Have you ever served with or processed for any branch of service? If yes, what branch and when?

Do you exercise on a regular basis? If yes, what do you do?

How did you hear about the program?

Date and time you are available for an appointment to discuss program options?

Why do you want to be a Marine Corps Officer?

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	Are you Qualified? Full Name: College/University: Major: Projected Graduation Date: Are you currently enrolled full-time (12 or more credits)?: Last Semester's GPA: Cumulative GPA: SAT/ACT scores: Are you a US Citizen?: Current Address: Phone at above address: Cell phone: Best time to call: Alternate e-mail: Home Address: Phone at home address: Date of Birth: Place of birth (City and State): Height: Weight: Do you have 20/20 vision? If not, what is it and are you correctable to 20/20?: Are you color blind or color deficient?: Do you have any other vision problems or have you had eye surgery? Has a doctor ever diagnosed you with asthma? If yes, were you ever prescribed an inhaler? If yes, when is that last time you used an inhaler?: Has a doctor ever prescribed an inhaler for anything other than asthma? Have you ever been diagnosed by a doctor with any allergies? If yes, what are you allergic too?: Are you currently taking any prescribed medications? If yes, what are they and for what reason are you taking them?: If not, have you ever taken any prescribed medication in the past for anything other than illness/flu?: Have you ever taken any medication to improve/alter your mood (Ritalin, Wellbutrin, Straterra, Zoloft, Prozac, or anything similar)? If yes, what and for what reason?: Any known diseases or illness in your medical history? If yes, what are they?: Have you ever been hospitalized overnight? If yes, for what?: Have you ever had surgery? If yes, what for and when?: Do you have any pins, plates, screws, rods, or metal permanently placed in your body? If yes, what and where? Have you ever seen a doctor for any reason other than minor conditions or routine physicals? If yes, for what? Have you ever seen a counselor, psychiatrist or psychologist? If yes, for what? Were you prescribed any medication? If yes, what was it and how long did you take it? Do you currently wear braces? If yes, when will they be removed? Do you have any tattoos? If yes, how many, what are they, where are they located? Have you ever had any tattoos removed? Do you currently have any body piercings, other than your ears (if female)? If yes, what and where? Have you ever had a traffic citation (speeding, parking, moving violation, red light), since you have had your driver's license? If yes, what for and when? Have you ever had your driver's license suspended or taken away by authorities? If yes, for what? Have you ever been arrested or charged with a crime, as an adult or juvenile? (Even if you were told that the record was sealed) If yes, what for and when? Have you ever tried marijuana? If yes, how many times/when was the last time? Have you ever used any other illegal drugs? If yes, which drugs have you used and when was the last time? What is your current marital status? Do you have any children? If yes, how many? Have you ever served with or processed for any branch of service? If yes, what branch and when? Do you exercise on a regular basis? If yes, what do you do? How did you hear about the program? Date and time you are available for an appointment to discuss program options? Why do you want to be a Marine Corps Officer? Back to Contact Us - Top of Page