DA Form 4571-r Data Required by the Privacy Act of 1974 (Eligibility for Amedd Officer Procurement Programs Miscellaneous Documentation)

DA Form 4571-r - also known as the "Data Required By The Privacy Act Of 1974 (eligibility For Amedd Officer Procurement Programs Miscellaneous Documentation)" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 4571-r - was last revised on November 1, 1983. Download an up-to-date fillable PDF version of the DA 4571-r below or request a copy through the chain of command.

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DATA REQUIRED BY THE PRIVACY ACT OF 1974
(ELIGIBILITY FOR AMEDD OFFICER PROCUREMENT PROGRAMS - MISCELLANEOUS DOCUMENTATION)
For use of this form, see AR 135-101; the proponent agency is the Office of The Surgeon General.
AUTHORITY: 10 USC 3012, 10 USC 4301.
PRINCIPAL PURPOSE: To determine your qualifications for appointment as an officer in the US Army Medical
Department or for selection for participation in an AMEDD officer procurement program. Your Social Security
Number (SSN) is necessary to identify you and your records and to report your earnings as a US Army member to
the Social Security Administration and Internal Revenue Service. This statement is applicable to documentation listed
below.
ROUTINE USES: This information will be used to evaluate your qualifications for assignment to various career areas;
to determine educational and experience background for award of constructive service credit; to determine dates of
service and seniority; to document your service agreement with the US Army; to provide a security determination for
either initial entry or retention in the US Army or for access to classified defense information to consider your request
for waiver of eligibility requirements; and for such other routine actions necessary for your accession into the US
Army. If you are accepted and subsequently commissioned as a US Army officer, the information (except letters of
recommendation, motivation statements, and interview evaluations) becomes part of your military personnel records for
promotion, reassignment, training, medical support, and other personnel management actions for you. Letters of recom-
mendation, motivation statements, and interview results remain a part of the procurement file, which is destroyed in
accordance with current regulations governing files disposition.
DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER AND OTHER PERSONAL INFORMATION IS VOLUNTARY. HOWEVER,
FAILURE TO FURNISH THE REQUESTED INFORMATION WILL RESULT IN INCOMPLETE APPLICATION AND DENIAL OF
APPOINTMENT/ACTIVE DUTY CONSIDERATION, AS APPROPRIATE.
Your signature below merely acknowledges that you have been advised of the foregoing.
MISCELLANEOUS FORMATS
First Year Graduate Medical Education Program Application
Curriculum vitae to include membership in professional organizations
Resume/autobiography
Transcripts
Letters of Recommendation
Interview evaluation
Proof of professional qualification
Courses in progress
Special test results
Motivation statements
Citizenship statements
Statement of understanding for accelerated appointment in the USAR without concurrent active duty before
complete medical examination and required NAC
Statement of professional school acceptance or enrollment
Institution statement on date degree requirements are to be completed
Statement of Understanding for Appointment as a USAR Commissioned Officer with Concurrent Call to Active
Duty Pending Completion of All Appointment Requirements
Information on Applicant for US Army Nurse Corps
Conditional release for transfer between components of the uniformed services
Statement of past and current professional status regarding:
(1) Malpractice claims and/or suits
(2) Withdrawal or denial of professional privileges at any health facility
Request for waiver of eligibility requirements
Conscientious objector statements
NAME OF APPLICANT (Typed or Printed)
SIGNATURE OF APPLICANT
DATE
DA FORM 4571-R, NOV 1983
APD LC v1.01ES
EDITION OF 1 JUL 79 IS OBSOLETE.
DATA REQUIRED BY THE PRIVACY ACT OF 1974
(ELIGIBILITY FOR AMEDD OFFICER PROCUREMENT PROGRAMS - MISCELLANEOUS DOCUMENTATION)
For use of this form, see AR 135-101; the proponent agency is the Office of The Surgeon General.
AUTHORITY: 10 USC 3012, 10 USC 4301.
PRINCIPAL PURPOSE: To determine your qualifications for appointment as an officer in the US Army Medical
Department or for selection for participation in an AMEDD officer procurement program. Your Social Security
Number (SSN) is necessary to identify you and your records and to report your earnings as a US Army member to
the Social Security Administration and Internal Revenue Service. This statement is applicable to documentation listed
below.
ROUTINE USES: This information will be used to evaluate your qualifications for assignment to various career areas;
to determine educational and experience background for award of constructive service credit; to determine dates of
service and seniority; to document your service agreement with the US Army; to provide a security determination for
either initial entry or retention in the US Army or for access to classified defense information to consider your request
for waiver of eligibility requirements; and for such other routine actions necessary for your accession into the US
Army. If you are accepted and subsequently commissioned as a US Army officer, the information (except letters of
recommendation, motivation statements, and interview evaluations) becomes part of your military personnel records for
promotion, reassignment, training, medical support, and other personnel management actions for you. Letters of recom-
mendation, motivation statements, and interview results remain a part of the procurement file, which is destroyed in
accordance with current regulations governing files disposition.
DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER AND OTHER PERSONAL INFORMATION IS VOLUNTARY. HOWEVER,
FAILURE TO FURNISH THE REQUESTED INFORMATION WILL RESULT IN INCOMPLETE APPLICATION AND DENIAL OF
APPOINTMENT/ACTIVE DUTY CONSIDERATION, AS APPROPRIATE.
Your signature below merely acknowledges that you have been advised of the foregoing.
MISCELLANEOUS FORMATS
First Year Graduate Medical Education Program Application
Curriculum vitae to include membership in professional organizations
Resume/autobiography
Transcripts
Letters of Recommendation
Interview evaluation
Proof of professional qualification
Courses in progress
Special test results
Motivation statements
Citizenship statements
Statement of understanding for accelerated appointment in the USAR without concurrent active duty before
complete medical examination and required NAC
Statement of professional school acceptance or enrollment
Institution statement on date degree requirements are to be completed
Statement of Understanding for Appointment as a USAR Commissioned Officer with Concurrent Call to Active
Duty Pending Completion of All Appointment Requirements
Information on Applicant for US Army Nurse Corps
Conditional release for transfer between components of the uniformed services
Statement of past and current professional status regarding:
(1) Malpractice claims and/or suits
(2) Withdrawal or denial of professional privileges at any health facility
Request for waiver of eligibility requirements
Conscientious objector statements
NAME OF APPLICANT (Typed or Printed)
SIGNATURE OF APPLICANT
DATE
DA FORM 4571-R, NOV 1983
APD LC v1.01ES
EDITION OF 1 JUL 79 IS OBSOLETE.

Download DA Form 4571-r Data Required by the Privacy Act of 1974 (Eligibility for Amedd Officer Procurement Programs Miscellaneous Documentation)

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