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APPLICATION FOR APPOINTMENT AND STATEMENT OF PREFERENCES FOR RESERVE OFFICE (SEE INSTRUCTIONS ON BACK)

From: (Last Name) (First Name) (Middle Name) Date

To: The Adjutant General, Washington, D.C.
(Through Corps Area or Department Commander)

I hereby make application for appointment as (Grade) (Section) in the Officers' Reserve Corps.

In connection with the application I submit the following information, which I certify to be correct to the best of my knowledge:

1. Permanent Address

2. Date of birth (Month) (Day) (Year) White or colored

3. Place of birth

4. State whether or not you are a citizen of the United States and whether by birth or naturalization. (If the latter, append evidence of naturalization, or if evidence not available, state on what date and in what court naturalized.)

5. Married or single

6. Number of minor children

7. Name of nearest relative, giving relationship and address, including street and number:

8. Father's name* (Last Name) (First Name) (Middle Name)
Father's address (Number and street, or rural route)
(City, town, or post office) (State or country)
Father's birthplace
If of foreign birth, state whether or not naturalized. (If naturalized, state on what date and in what court.)

Mother's name† (Present last name) (First name) (Middle name) 
Mother's address‡  (Number and street, or rural route)
(City, town, or post office) (State or country)

9. Marksmanship, giving year of qualification:
Rifle
Pistol

* In giving the names of the father or mother, if either is deceased it will be noted following the name.
† In giving the mother's last name, that which she bears at present will be given.
‡ If the mother's address is the same as the father's, it will be so noted and not repeated
W.D., A.G.O. Form No. 170 January 1, 1935

10. Languages:
[[six column table]]
| --- | French | Spanish | German | Other | Other |
| Speaks fluently | --- | --- | --- | --- | --- |
| Speaks Fairly | --- | --- | --- | --- | --- |
| Translates | --- | --- | --- | --- | --- |
| Reads | --- | --- | --- | --- | --- |

11. Special knowledge, professional or other

12. Present occupation, years of experience in same and name and address of employer, if any

13. Experience in other lines and years of same

14. Schools attended, other than graded schools, including service schools:

[[5 columned table]]

| Name of school | Number of years attended | Graduated | Yes or no/ Year | Degrees |

Subjects specialized in

15. Campaigns and battles participated in (give dates)

16. Decoration, citations, and commendations (attach copies)

17. Wounds, giving date and place of occurrence

18. State membership in professional societies

19. Are you at present a member of the Regular Army, Enlisted Reserve Corps, or federally recognized in the National Guard? If so, state which, given grade and organization or arm or service and date of expiration of enlistment:

3-7585

Transcription Notes:
Blank form.