DA Form 1696 Vaccine Consent and Assessment

DA Form 1696 - also known as the "Vaccine Consent And Assessment" - 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 1696 - was last revised on April 1, 2005. Download an up-to-date fillable PDF version of the DA 1696 below or request a copy through the chain of command.

ADVERTISEMENT
APPLICATION FOR:
ENLISTMENT/REENLISTMENT QUALIFYING APPLICATION
(SPECIALLY RECRUITED PERSONNEL)
ENLISTMENT
For use of this form, see AR 601-210; the proponent agency is DCS, G-1.
REENLISTMENT
1. NAME (Last, First, Middle Initial)
2. FORMER SERVICE NUMBERS
3. DATE OF BIRTH
4. PHYSICAL PROFILE
5. AFQT TEST AND SCORES
6.
PRIOR ACTIVE FEDERAL SERVICE
COMPONENT OR SERVICE
FROM
TO
MOS CODE
GRADE
YEARS
MONTHS
DAYS
TOTAL ACTIVE FEDERAL SERVICE
7. DESCRIPTION OF MAJOR DUTY ASSIGNMENTS ON ACTIVE DUTY
8.
SERVICE SCHOOL COURSES COMPLETED
YEAR
COURSE
MOS CODE
SCHOOL AND LOCATION
LENGTH OF COURSE
ATTENDED
9.
INACTIVE FEDERAL SERVICE
COMPONENT OR SERVICE
FROM
TO
MOS CODE
GRADE
YEARS
MONTHS
DAYS
TOTAL INACTIVE FEDERAL SERVICE
DA FORM 1696, APR 2005
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
APD LC v1.01ES
APPLICATION FOR:
ENLISTMENT/REENLISTMENT QUALIFYING APPLICATION
(SPECIALLY RECRUITED PERSONNEL)
ENLISTMENT
For use of this form, see AR 601-210; the proponent agency is DCS, G-1.
REENLISTMENT
1. NAME (Last, First, Middle Initial)
2. FORMER SERVICE NUMBERS
3. DATE OF BIRTH
4. PHYSICAL PROFILE
5. AFQT TEST AND SCORES
6.
PRIOR ACTIVE FEDERAL SERVICE
COMPONENT OR SERVICE
FROM
TO
MOS CODE
GRADE
YEARS
MONTHS
DAYS
TOTAL ACTIVE FEDERAL SERVICE
7. DESCRIPTION OF MAJOR DUTY ASSIGNMENTS ON ACTIVE DUTY
8.
SERVICE SCHOOL COURSES COMPLETED
YEAR
COURSE
MOS CODE
SCHOOL AND LOCATION
LENGTH OF COURSE
ATTENDED
9.
INACTIVE FEDERAL SERVICE
COMPONENT OR SERVICE
FROM
TO
MOS CODE
GRADE
YEARS
MONTHS
DAYS
TOTAL INACTIVE FEDERAL SERVICE
DA FORM 1696, APR 2005
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
APD LC v1.01ES
10.
CIVILIAN EDUCATION
LEVEL
NAME AND LOCATION OF SCHOOL
MAJOR OR SPECIALITY
DEGREE
YEAR
HIGH SCHOOL
COLLEGE
UNIVERSITY
POST GRADUATE
OTHER EDUCATION AND DESCRIPTION OF TRAINING WHICH QUALIFIES FOR ENLISTMENT/REENLISTMENT SPECIFIED
11.
CIVILIAN EMPLOYMENT SINCE DATE OF LAST SEPARATION FROM THE ARMED FORCES
(If additional space is required, use additional sheet of paper)
FROM (Date)
TO (Date)
EMPLOYER AND ADDRESS
DESCRIPTION OF DUTIES AND RESPONSIBILITIES
FROM (Date)
TO (Date)
EMPLOYER AND ADDRESS
DESCRIPTION OF DUTIES AND RESPONSIBILITIES
12. LIST OF SUPPORTING DOCUMENTS (Attached)
13.
STATEMENT OF APPLICANT
I,
, DO HEREBY ACKNOWLEDGE THAT I HAVE EXAMINED IN DETAIL THE DATA AND
INFORMATION PRESENTED HEREIN AND THAT THE SAME ARE TRUE, COMPLETE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
14. RECOMMENDATIONS OF RECRUITING OFFICER TO INCLUDE MOS AND GRADE;
TYPED NAME, GRADE, AND ORGANIZATION OF RECRUITING OFFICER
SIGNATURE
DA FORM 1696, APR 2005
Page 2 of 2
APD LC v1.01ES

Download DA Form 1696 Vaccine Consent and Assessment

844 times
Rate
4.5(4.5 / 5) 90 votes
ADVERTISEMENT
Page of 2