DA Form 4213 Supplemental Data for Army Medical Service Reserve Officers

DA Form 4213 - also known as the "Supplemental Data For Army Medical Service Reserve Officers" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 4213 - was last revised on April 1, 1976. Download an up-to-date fillable PDF version of the DA 4213 down below or look it up on the Army Publishing Directorate website.

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SUPPLEMENTAL DATA FOR ARMY MEDICAL SERVICE RESERVE OFFICERS
FOR ARMY SURGEON'S
USE ONLY
For use of this form, see AR 135-133; the proponent agency is Office of The Surgeon General.
DATE
INSTRUCTIONS
1. COMPLETE ALL ITEMS each time this
4. Use blank sheet for continuation of
PRIMARY MOS
form is used.
items, identifying by item number.
2. Use "NONE" where applicable.
5. Type or print.
SECONDARY MOS
3. Complete in triplicate.
6. Date and sign original and two copies.
1. NAME (Last, first, middle initial) GRADE AND SERVICE NUMBER
2. HOME ADDRESS (Including ZIP code)
3. DATE OF BIRTH
4. SEX
5. MARRIED
6. NO of DE-
7. PRESENT OCCUPATION (Duty and station if on active duty)
PENDENTS
Yes
No
8. BRANCH
9. PRESENT UNIT OR ORGANIZATION OF ASSIGNMENT
10. TDA/ TOE POSITION OCCUPIED
14. COMMIS-
15. ENLISTED
16. TOTAL
11. PRIMARY MOS
12. SECONDARY MOS
13. DATE OF INITIAL
MONTHS
APPOINTMENT
SIONED
ACTIVE
DUTY
EDUCATION AND TRAINING
SCHOOLS ATTENDED
YRS ATTENDED
DATE GRADUATED
INSTITUTION AND LOCATION
DEGREE
MAJOR SUBJECTS
FROM
THRU
DAY
MO
YR
17.
HIGH
SCHOOL
18.
COL-
LEGE
19.
20.
PROFES-
SIONAL
21.
SCHOOL
INTERNSHIP, RESIDENCY AND FELLOWSHIP
DATE COMPLETED
TIME
HOSPITAL AND LOCATION
TYPE
DAY
MO
YR
MONTHS
22.
INTERN-
SHIP
23.
24.
RESI-
DENCY
25.
AND
FELLOW-
26.
SHIP
MILITARY SCHOOLING AND TRAINING
DATES OF TRAINING
SCHOOL OR STATION AND LOCATION
COURSE OR TYPE OF TRAINING
FROM
THRU
27.
28.
29.
30.
CERTIFICATIONS
31. CERTIFIED BY EDUCATIONAL COUNCIL
32. TYPE OF CERTIFICATION
33. DATE ISSUED
34. EXPIRATION DATE
FOR FOREIGN MEDICAL GRADUATES
STANDARD
TEMPORARY
YES
NO
35. CERTIFIED BY THE AMERICAN BOARD OF: 36. DATE
37. SUBSPECIALTY (Recognized by an American
38. DATE
Specialty Board after examination)
39. CURRENT LICENSE OR REGISTRATION (Identifying No., State or National and Year,
40. DIPLOMATE OF NATIONAL BOARD OF
MEDICAL EXAMINERS
limitations, if any)
YES
NO
DA FORM 4213, APR 1976
Page 1 of 2
EDITION OF 1 FEB 74 MAY BE USED.
APD LC v1.01ES

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