UNIT POC: POC PHONE: POC EMAIL:

INCLUSIVE DATES START END Number ofOF ORDERS DATE DATE Days

YES NO DATE1. FTNGD CHECKLIST - (This checklist)

3. SF 52 for Termination or Absent US if in a technician status

(Obtained from Unit Readiness NCO)

(Ensure MED DET updates your MEDPROS and signs MEDPROS printout)

FTNGD Checklist October 2011

S1 completes blocks 25 to 36d.

All info MUST be updated, if not UNIT needs to get info to Med Det to update

9. RPAM (RETIREMENT POINT ACCOUNTING STATEMENT)

B. MRD/ETS - (Must not be within 6 mos of tour end date)

Not more than 30 days old.

Cannot serve over 17 years of AS as a result of this duty

10. Counseling Form 4856

11. UNIT COMMANDER'S RECOMMENDATION (Not older than 30 days)Unit Commander's Recommendation formatted IAW IDARNG 600-8-105, Pg.14, Fig 2-3

Part 1 Filled out by soldier. Part 3 must be signed and dated by soldier and supervisor

6. PREGNANCY TEST (HCG Screen within 15 days of start date) (if applicable)

7. DA FORM 5500 (IF APPLICABLE) OR Certified Height/Weight if Within ScreeningTable Weight AR 600-9 Table 1 (Must be weighed within 30 days prior to start date)

8. PQR-B (CURRENT)

All information must be updated OR supporting Docs attached to packet

A. DA 705 - APFT Scorecard (PT Test must not be more than 12 mos old)

SM fills out blocks 2 to 24, sign and date blocks 22 & 24.

Unit Commander must sign & date BLK 35e

5. MEDPROS IMR Record

B. Deployment Limitations No Temporary Profiles

C. HIV results on MEDPROS print-out (within 2 yrs of start date)

DA form 3349 required for soldiers w/ permanent profiles

A. Chapter 2 or 3 physical on MEDPROS IMR

PHA within 12 months of start date or Physical not more than 12 months old

REQUIREMENT

2. SF 52 Completed In Accordance with Tab P FTNG - ADOS

4. DA Form 1058-R (Jul 93) , APPLICATION FOR ADOS TOUR

Full-time National Guard Duty (FTNGD) CHECKLISTNAME: SSN:

UNIT Name: UIC:

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APPLICATION FOR ACTIVE DUTY FOR TRAINING, ACTIVE DUTY FOR SPECIAL WORK, TEMPORARYTOUR OF ACTIVE DUTY, AND ANNUAL TRAINING FOR SOLDIERS OF THE ARMY NATIONAL GUARD

AND U.S. ARMY RESERVEFor use of this form, see AR 135-200; the proponent agency is ODCSPER

ROUTINE USES:

5a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (Ifdifferent from permanent home address) (Include ZIP Code)

18. TOTAL YEARS, MONTHS, DAYS OF ACTIVEFEDERAL SERVICE (AFS)

17.

EDITION OF MAR 90 IS OBSOLETE

AUTHORITY:PRINCIPAL PURPOSE:

DISCLOSURE:

DA FORM 1058-R, JUL 93

DATA REQUIRED BY THE PRIVACY ACT OF 197410 USC 672(d) and USC 275.

To determine eligibility and schedule individuals for active duty for special work or active duty for trainingon requested dates.

To identify the applicant as a Reserve Component member and to issue active duty for special work oractive duty for training orders. The SSN is used to identify the applicant.

Completing this form is mandatory for individuals applying for active duty for special work and active dutyfor training. If not completed, you will be ineligible for the requested tour.

PART I - APPLICANT (Read instructions in AR 135-200 before completing this form.)

9. SEX

Male Female

I am I am not drawing a pension, disability compensation,or retired pay from the U.S. Government.

20. DATES OF ADSW/TTAD/ADT/AT REQUESTED

a. FIRST CHOICE b. SECOND CHOICE

21. To the best of my knowledge and belief, I am physically qualified for active military duty. I was

19. FOR INDIVIDUAL MOBILIZATION AUGMENTEES ONLY: THIS APPLICATION IS FOR (Check one)

IMA AT ADT in lieu of IMA AT Additional ADT

USAPPC V2.00

2. NAME (Last, First, MI) 3. SSN

4b. HOME TELEPHONE NUMBER (Include area code) 5b. HOME TELEPHONE NUMBER (Include area code)

4c. BUSINESS TELEPHONE NUMBER (Include area code) 5c. BUSINESS TELEPHONE NUMBER (Include area code)

6. UNIT OF ASSIGNMENT OR ATTACHMENT 7. GRADE 8. BRANCH

11. MARITAL STATUS 12. NO. OF DEPENDENTS10. DOB

13. PRIMARY SSI (AOC)/MOS 14. DUTY SSI (AOC)/MOS 15. HEIGHT 16. WEIGHT

NUMBER OF DAYS BEGINNING DATE/TIME

LOCATION

4a. PERMANENT HOME ADDRESS (Include ZIP Code)

1. TO (Include ZIP Code)

22. SIGNATURE

NUMBER OF DAYS BEGINNING DATE/TIME

LOCATION

DUTY/TRAINING AGENCY DUTY/TRAINING AGENCY

a. LAST EXAMINED ON b. AT

23. DATE

24. REMARKS

I understand that although at the completion of my tour I may be within 2 years of qualifying for an active duty retirement under 10 USC 1293, 3911, or 3914, it is current Army policy that I will be released from active duty at the completion of my tour unlesscontinued retention on active duty is considered in the best interest of the Army by the Assistant Secretary of the Army (Manpowerand Reserve Affairs). I hereby consent to my release from active duty at the completion of this tour.

27. PROMOTIONCONSIDERATION CODE

31. MANDATORY REMOVALDATE (Officers)

a. PERIOD OF TRAINING/DUTY

35. List all previous AD, TTAD, AT, ADT, IADT, and ADSW in the previous and current fiscal year showing inclusive dates, purposeof tours, and HQ or agency to which attached.

(Signature of applicant)

PART II - RECORDS CUSTODIAN

34. PANOGRAPHIC DENTAL X-RAY ON FILE YES NO

FROM TO NO.DAYS

d. DUTYPERFORMED

REVERSE, DA FORM 1058-R, JUL 93 USAPPC V2.00

b. TYPE TRAINING/DUTY

(AD, TTAD, etc.)c. LOCATION/INSTALLATION

e. SIGNATURE OF UNIT COMMANDER

29. RYE DATE

26. SECURITY CLEARANCE 28. DATE OF RANK

30. ETS (Enlisted) 32. UIC

33. HIV TEST DATE

f. DATE

25. PAY ENTRY BASIC DATE

c. SIGNATURE

36a. NAME OF RECORDS CUSTODIAN (First, Last, MI)

d. DATE

b. GRADE

Initial counseling prior to selection for a Full-Time National Guard Duty (FTNGD) position. Listed below are conditions ofemployment and must be acknowledged prior to starting the application process.

Key Points of Discussion:

1. By printing and signing my name in the spaces provided below, I acknowledge that I have read and understand all the requirementsand responsibilities stated in IDARNG Policy Memos #12 and #32.

____________________________________ _________________________________Print Name Signature

2. I must maintain and update my DA 481 in coordination with my supervisor to track my leave. I will ensure that my DA 481 is sentthrough HRO to USPFO by my unit at the end of my tour. I acknowledge that I will use all of the leave that I earn during this tourand that I am not authorized to carry-over or sell back any leave.

3. It is my responsibility to properly complete a DA 31 for periods of leave that I take, and ensure that a printed DA 31 is submittedthrough HRO to USPFO upon completion of each leave period that I take. I will also maintain a personal copy of all my DA 31's forfuture reference.

4. Orders must be published prior to me reporting for duty.

5. It is my responsibility to ensure that mypacket is complete to the best of my knowledge in accordance with the FTNGDchecklist and the reverse side of this counseling form prior to turn-in to the HRO.

6. I acknowledge that if I am involuntarily released from this tour early due to misconduct, inefficiency, or deficiency on my part, Iwill be notified by my supervisor in writing and will be given a minimum of 15-days prior to release. I further acknowledge that Ihave 5 working days after notification to rebut the termination and that my rebuttal will accompany my notification of releasethrough my chain of command to the AG. I understand that I must use all of my leave before my last day of duty.

Name (Last, First, MI) Rank/Grade Date of Counseling

Organization Name and Title of Counselor

Purpose of Counseling: (Leader states the reason for the counseling, e.g. Performance/Professional or Event-Oriented counseling, and includesthe leader's facts and observations prior to the counseling.)

Key Points of Discussion:

DEVELOPMENTAL COUNSELING FORMFor use of this form, see FM 6-22; the proponent agency is TRADOC.

DATAREQUIRED BY THE PRIVACY ACT OF 1974

AUTHORITY:

PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:

5 USC 301, Departmental Regulations; 10 USC 3013, Secretary of the Army.

To assist leaders in conducting and recording counseling data pertaining to subordinates.

The DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems or records notices alsoapply to this system.

Disclosure is voluntary.

PART I - ADMINISTRATIVE DATA

PART II - BACKGROUND INFORMATION

PART III - SUMMARY OF COUNSELING

Complete this section during or immediately subsequent to counseling.

OTHER INSTRUCTIONS

This form will be destroyed upon: reassignment (other than rehabilitative transfers) , separation at ETS, or upon retirement. For separationrequirements and notification of loss of benefits/consequences see local directives and AR 635-200.

PREVIOUS EDITIONS ARE OBSOLETE.DA FORM 4856, AUG 2010 APD PE v1.00ES

FTNGD APPLICATION CHECKLIST:1. Complete all required entries on DA Form 1058-R JUL 93, by completing blocks 2-24, certifyall information by signing anddating blocks 22 and 24.

a. S1 completes blocks 25-36d.b. Obtain your unit commander's signature in block 35e on DA 1058-R.c. Request commander's letter of recommendation. (Use the format contained in IDARNG 600-8-105, Page 14, Figure 2-3)

2. From your unit of assignment:a. Certified height/weight or DA 5500R (males) or DA 5501R (females). (Not more than 30 days as of start date)b. DA 705 (APFT score card), and DA 3349 if applicable. (Record test with-in 12 months of start date)

3. After obtaining unit commander approval and recommendation:a. Print your MEDPROs IMR Record. This can be obtained by accessing your AKO account / My Medical / My Medical

Readiness / View Detailed Information / IMR Record.(Ensure you have the Medical Detachment update your MEDPROS and sign your MEDPROS printout)

b. Coordinate with Health Services for HIV and Pregnancy test as appropriate.4. Turn in the aforementioned documentation to the agency you intend on working for.5. The agency you are working for will review the application for content; finalize the required SF 52 justification memo. Theywill then turn your packet into the AGR Branch.6. Failure to follow the above instruction will slow down your application process.

1. Forward FTNGD application through approval authorities to HRO.2. Assist soldier in the management of accrued leave by maintaining DA 481.3. Ensure the soldier obtains an Active Duty card and applies for TriCare Prime Remote for self and family.4. Ensure that FTNGD orders are published prior to start date of tour.5. Ensure adequate physical fitness time is provided (3-5 hrs per week).

Plan of Action

:(Outlines actions that the subordinate will do after the counseling session to reach the agreed upon goal(s). The actions must be

specific enough to modify or maintain the subordinate's behavior and include a specified time line for implementation and assessment (Part IV below)

Individual counseled remarks:

Leader Responsibilities: (Leader's responsibilities in implementing the plan of action.)

Assessment: (Did the planof action achieve the desired results? This section is completed byboth the leader and the individual counseledand provides useful information for follow-up counseling.)

REVERSE, DA FORM 4856, AUG 2010

Session Closing: (The leader summarizes the key points of the session and checks if the subordinate understands the plan of action. Thesubordinate agrees/disagrees and provides remarks if appropriate.)

Individual counseled: I agree disagree with the information above.

Signature of Individual Counseled: Date:

Signature of Counselor: Date:

PART IV - ASSESSMENT OF THE PLAN OF ACTION

Individual Counseled: Date of Assessment:Counselor:

Note: Both the counselor and the individual counseled should retain a record of the counseling.

APD PE v1.00ES

6.

1. LAST NAME, FIRST NAME, INITIALS & SSN

FROM PREVIOUS RECORD

BA

LAN

CE

AV

AIL

ABLE

b. SIGNATURE OF RESPONSIBLE OFFICER

13. SIGNATURE OF RESPONSIBLE OFFICER

MILITARY LEAVE RECORD For use of this form, see AR 37-104-3;

the proponent agency is USAFAC.

NO.OF

DAYS

a. DSSN OF FINANCE & ACCTG OFFICER

FROM

PAGES4. PAGEOF

TO

c. BALANCE

b. TOTAL DAYS LEAVE TAKEN

12. DSSN OF FINANCE & ACCTG OFFICER

(Specify)

LEAVE CREDITED

TOTYPE

LPMORNING REPORT

DESIGNATION AND UIC

PERIOD

FROM

DA

YS

EX-

CLU

DED

DA

YS L

VC

RED

ITED

DSSN

OF

F

& A

O

LEAVE TAKEN

a. b. d. e. a. b. c. d. e.c.

7. 8.

9. ABSENCES DURING WHICH LEAVE DOES NOT ACCRUE BY DATES AND SPECIFIC AUTHORITY FROM AR 630-5

TO DAYS AUTH MORNING REPORT UNIT FROM TO DAYS AUTH MORNING REPORT UNIT

RECORD CLOSING DATAFINAL COMPUTATION REMARKS10. 11.

a. CASH SETTLEMENT REQUESTED

b. OTHER DISPOSITION

DA FORM 481, MAY 73 EDITION OF 1 DEC 60, WILL BE USEDUNTIL EXHAUSTED.

USAPPC V1.00

FROM

a. TOTAL DAYS LEAVE CREDITED

(Total column 6c)

(Total column 8d)

(a minus b)

5

2. FROM (Date)

3. TO (Date)

LOCATION IDENTIFICATION OF DSSN

REVIEW AND VERIFICATION OF LEAVE BALANCE

ENTRIES

DSSN STATION ADDRESS DSSN STATION ADDRESS

FROM TO

LEAVEBALANCE

SERVICE MEMBER'S SIGNATURE RESPONSIBLE OFFICER'S SIGNATURE

USAPPC V1.00