ADOS Checklist

VOLUNTARY ADOS Checklist Version 8
T32 ADOS CHECKLIST
NAME:
DATE:
UNIT:
UNIT/ORGANIZATION WHERE ADOS WILL BE PERFORMED:
ADOS DUTY POSITION:
STATEMENT OF NEED:
PAARNG Application for Active Duty Operational Support (ADOS) Form
Block 22 Signed by Records Custodian
Block 24 Signed by Applicant
Block 33 Signed by Unit Commander and Records Custodian
Current NGB Form 23A, within 30 days of application date
Verification of security clearance memorandum from the State Security Manager, within 30
days of application date
DA Form 705 (Army Physical Fitness Test Scorecard) with Record-Go APFT score, within 60
days of application date.
DA 5500 or 5501 (Body Fat Content Worksheet), within 6 months of application start date
Waiver (1095/17 Years/Sanctuary/Separation Pay)
Pregnancy test results (Females Only), within 15 days of start date
HIV test, within last 2 years of start date
Current Individual Medical Readiness (IMR) Record indicating Periodic Health
Assessment (PHA), within one year of start date
Soldier Record Brief (SRB)
Do you agree to voluntarily attend IDT and AT periods?
Yes
Are you an Employee of the Commonwealth of Pennsylvania? Yes
Are you a Pennsylvania National Guard Technician?
Yes
or
or
No
or
No
No
APPLICANT SIGNATURE: ____________________________________
VOLUNTARY ADOS Checklist Version 8
POC: JFHQ-G3 (717) 861-6846
VOLUNTARY ADOS Checklist Version 8
T10 ADOS CHECKLIST
(for T10 tours, complete in addition to T32 ADOS checklist)
DA Form 1506 (Statement of Service), covering all active service over the last four years
DD Form 2648-1 (Pre-separation Counseling Checklist)
DD Form 2958 (Service Member Career Readiness Standards/Individual Transition
Plan Checklist)
VOLUNTARY ADOS Checklist Version 8
POC: JFHQ-G3 (717) 861-6846
PAARNG ADOS FORM
CHAIN OF COMMAND APPROVAL
I certify that SM took the APFT on _________ and is IAW AR 600-9.
I certify that all information found on the ADOS checklist and the ADOS form is correct and complete.
COMPANY/DET CDR SIGNATURE OR SIGNATURE AUTHORITY
BATTALION CDR SIGNATURE OR SIGNATURE AUTHORITY
BRIGADE CDR SIGNATURE OR SIGNATURE AUTHORITY
DIV/GRP CDR SIGNATURE OR SIGNATURE AUTHORITY
SUBJECT: Recommendation of approval for ADOS tour
This Command recommends approval for SM requesting to perform long-term ADOS.
(IF APPLICABLE) This Technician Supervisor approves SM request for long-term ADOS.
TECHNICIAN SUPERVISOR SIGNATURE
(IF APPLICABLE) This hiring agency accepts SM requesting to perform long-term ADOS, and agrees
to allow SM to perform IDT and AT unless prior coordination has been made.
HIRING AGENCY SIGNATURE
PAARNG ADOS Form
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PAARNG ADOS FORM
DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:
̀
32 USC 502
PRINCIPLE PURPOSE:
To determine eligibility and schedule individuals for active duty operational support (ADOS)
ROUTINE USES:
To identify the applicant as a Reserve Component member and to issue active duty
operational support orders.
DISCLOSURE:
Completing this form is mandatory for individuals applying for active duty operational support.
If not completed, applicant will not be eligible for the requested tour.
PART I - APPLICANT
1. TO
JFHQ-G3
2. NAME (Last, First, MI)
3. SSN
d
4a. PERMANENT HOME ADDRESS (Include ZIP code)
5a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (if
different from permanent home address) (include ZIP code)
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/MOS
9. SEX
10. D.O.B.
11. MARITAL STATUS
12. NO. OF DEPENDANTS
13. PRIMARY SSI (AOC)/MOS
14. DUTY SSI (AOC)/MOS
15. HEIGHT
16. WEIGHT
17.
drawing a pension, disability
compensation, or retired pay
from the U.S. Government
18. TOTAL AD Points
M
I am
F
I am not
19. SIGNATURE OF JFHQ HUMAN RESOURCE OFFICER VERIFYING ADMIN DATA IN BLOCK 18
20. DATES OF ADOS REQUESTED:
b. SECOND CHOICE
a. FIRST CHOICE
NUMBER OF DAYS
BEGINNING DATE/TIME
NUMBER OF DAYS
LOCATION
LOCATION
DUTY/TRAINING AGENCY
DUTY/TRAINING AGENCY
BEGINNING DATE/TIME
21. To the best of my knowledge and belief, I am physically qualified for active military service. I was:
a. LAST EXAMINED ON
b. LOCATION
22. SIGNATURE OF COMPANY RECORDS CUSTODIAN
23. DATE
PAARNG ADOS Form
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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 ADOS at the completion
of my tour unless I am offered a follow-on tour as approved by CNGB. I hereby waive sanctuary and consent to being
ordered to ADOS for a period indicated on my order and consent to my release from ADOS at the completion of this tour."
______________________________________________________
(Signature of applicant)
(THIS
ACTION WILL NOT BE APPROVED WITHOUT THE SOLDIER’S SIGNATURE IN THIS BLOCK)
____________________________________________________________________________________________________________________
ADDITIONAL REMARKS:
■ Identify Break In Service. (Used to compute / verify days elapsed since last active duty operational support tour (31-Day Break))
♦ (a) Date of the last day on ADOS status:
..
♦ (b) Date new tour of duty to start:
♦
Number of Days (subtract b from a):
PART II - RECORDS CUSTODIAN
25. PAY ENTRY BASIC DATE
28. RYE DATE
31. HIV TEST DATE
26. SECURITY CLEARANCE
27. DATE OF RANK
29. ETS (Enlisted)
30. MANDATORY REMOVAL DATE (Officers)
32. PANOGRAPHIC DENTAL X-RAY ON FILE
YES
NO
33. Preceding Duty: List all AD performed within the past 4 years. NGB FORM 23A must be attached IF number of points exceed 730 days.
a. PERIOD OF PRECEDING DUTY
FROM
TO
NO. AD PTS
b. TYPE OF AD
(B1 or B4 on NGB 23B)
c. LOCATION
INSTALLATION
d. DUTY
PERFORMED
SIGNATURE OF COMPANY COMMANDER OR SIGNATURE AUTH
DATE
GRADE
TITLE
SIGNATURE OF COMPANY RECORDS CUSTODIAN
DATE
GRADE
TITLE
NAME, SIGNATURE AND TELEPHONE NUMBER OF STATE ADOS APPROVING AUTHORITY
(Approving official check appropriate box)
THIS TOUR APPLICATION IS APPROVED
DATE
GRADE
THIS TOUR APPLICATION IS NOT
APPROVED
COL/O-6
NAME AND OFFICE OF POC
COL MARC FERRARO
PAARNG ADOS Form
COMMERCIAL AND DSN TELEPHONE
717-861-6846
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