Tattoo/Branding/Earlobe Gauging Screening
(For use of this form see USAREC Reg 601-96)
PRIVACY ACT STATEMENT
AUTHORITY: Collection of this information is authorized by 10 USC, sections 503, 505, 532, 12101 and Executive Order 9397.
PRINCIPAL PURPOSE: Information collected will be used to assist in the prequalification process.
ROUTINE USES: Blanket routine use disclosures as described in AR 340-21, paragraph 3-2.
DISCLOSURE: Voluntary; however, failure to provide the information may delay or terminate the enlistment process.
Mark tattoo/brand/earlobe gauging on the body with a number.
FRONT
BACK
Describe tattoo/brand/earlobe gauging below by corresponding number marked on the body. Indicate meaning next to corresponding
number for all tattoos and brands only. For applicants with earlobe gauging indicate measurements at Dep in and Dep out.
( E xa m p l e ) T a t t o o : H e a r t w i t h n a m e
M e an i ng : D au g ht e r' s n a m e - sh e i s m y h ea rt
(Example) Right earlobe gauge size .25 inches
Date measured 21 Sep 12
Right earlobe gauge size .25 inches
Remeasured 19 Oct 2012
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5.
USAREC Form 1241, Rev 1 Oct 12
PREVIOUS EDITIONS ARE OBSOLETE
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DEP-IN:
I verify that I do
do not
have any tattoos, brands or earlobe gauging.
Applicant's Typed Name
A p pl i ca nt ' s S i g n at u re
The above tattoos/brands/earlobe gauging are
are not
Recuriter Typed Name, Grade, RSID
may not be
in accordance with AR670-1 and current policy.
R e c ru i t e r S i g n a t u r e
The above tattoos/brands/earlobe gauging are
are not
RS/C Commander Typed Name, Grade, RSID
may not be
D a te
in accordance with AR670-1 and current policy.
R S / C C o m m an d e r S i g n a t ur e
The above tattoos/brands/earlobe gauging are
are not
Company Commander or First Sergeant Typed Name
The above tattoos/brands/earlobe gauging are
are not
GC Typed name, grade, MEPS ID
may not be
Company Commander/First Sergeant Signature
may not be
Battalion Commander or XO Typed Name and Grade
disapproved
D a te
in accordance with AR670-1 and current policy.
Date
in accordance with AR670-1 and current policy.
G C S i g n a tu r e
The above tattoos/brands/earlobe gauging are approved
D a te
D a te
in accordance with AR670-1 and current policy.
B a t t a l i o n C o m m a n d e r/ X O S i g n a t u re
D a te
DEP-OUT:
All additional tattoos/brands/earlobe gauging have been added to drawing above.
The above tattoos/brands/earlobe gauging are
I have
have not
are not
may not be
in accordance with AR670-1 and current policy.
obtained any additional tattoos/brands or earlobe gauging since I entered the DEP/DTP.
Applicant's Typed Name
The above tattoos/brands/earlobe gauging are
A p pl i ca nt ' s S i g n at u re
are not
Recruiter Typed Name, Grade, RSID
The above tattoos/brands/earlobe gauging are
in accordance with AR670-1 and current policy.
R e c ru i t e r S i g n a t u r e
are not
RS/C Commander Typed Name, Grade, RSID
The above tattoos/brands/earlobe gauging are
may not be
may not be
may not be
Company Commander/First Sergeant Signature
The above tattoos/brands/earlobe gauging are
may not be
GC Typed name, grade, MEPS ID
The above tattoos/brands/earlobe gauging are approved
Battalion Commander or XO Typed Name and Grade
USAREC Form 1241, Rev 1 Oct 12
Date
in accordance with AR670-1 and current policy.
G C S i g n a tu r e
disapproved
D a te
in accordance with AR670-1 and current policy.
Company Commander or First Sergeant Typed Name
are not
D a te
in accordance with AR670-1 and current policy.
R S / C C o m m an d e r S i g n a t ur e
are not
D a te
D a te
in accordance with AR670-1 and current policy.
B a t t a l i o n C o m m a n d e r/ X O S i g n a t u re
PREVIOUS EDITIONS ARE OBSOLETE
D a te
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Continuation page:
Describe tattoo/brand/earlobe gauging below by corresponding number marked on the body. Indicate meaning next to corresponding number for all
tattoos and brands only. For applicant with earlobe gauging indicate measurements as Dep in and Dep out.
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Additional Information/Comments:
USAREC Form 1241, Rev 1 Oct 12
PREVIOUS EDITIONS ARE OBSOLETE
LFV 2.00
Page 3of3