Name: SSAN:DOB: Height: inches Weight: Unit:

Appointment ( ) ( ) ( )Promotion ( ) ( ) ( )Reassignment/Trnsfr ( ) ( ) ( )OCS Application ( ) AGTX Form 67 ( )Award ( ) Total TXSG Time Time in Current Grade

Prior Fed Grade Prior Fed Svc TimeGrade: 2LT 1LT CPT WO1 Time in Current Asgn Current Age/Yrs CW2 CW3 CW4 CW5 MAJ LTC COL Civilian Education CompletedAssignment:Line_# Off/WO Military Education (circle one)

OBC, OAC, C&SC 1/2 or Comp, War Coll Time in Current Asgn Current Age/Yrs

From: Military Education Compl (circle one) [ ] Past Waivers?Promotion to:_________ OBC, OAC, C&SC 1/2 or Comp, War Coll[ ] Brevit w/Tsfr to HRR or RR [ ] Meets TXSG Reg 600-10 minimum requirements

[ ] Vacancy exists for Position Requested? From: [ ] Does grade requested exceed position auth? To: [ ] If PBO, has property been transferred? N/A

Downgraded to :LS DSM TxOSM TxMOM AGIA CGIA MSRTxOSM Certificate of AppreciationTxMOM

Post Board Action Military Education RequirementsNot Required [ ] [ ] Soldier must complete PreCommission CourseRequired [ ] [ ] Officer must complete OBC within 18 months of Appt/Prom

[ ] Officer must complete OBC within 24 months of Appt/Prom[ ] Officer must complete OAC within 18 months of Appt/Prom[ ] Officer must complete OAC within 24 months of Appt/Prom

Member # 1: 1 2 3 4 5 6 [ ] Resubmit with certificate of Completion 50% CGSC(4 courses)Member # 2: 1 2 3 4 5 6 [ ] Soldier must consult physician & enroll in weight controlMember # 3: 1 2 3 4 5 6Member # 4: 1 2 3 4 5 6 Member # 5: 1 2 3 4 5 6

Total Score In Person [ ]Mail [ ] TXSG Form 23 Prepared byTelephone [ ] Documents or Reqmnts Chkd by

Screening Bd RecorderAPPROVED [ ] Date: APPROVED [ ] Date: DISAPPROVED [ ] RETURNED w/o ACTION [ ] DISAPPROVED [ ]

Board President

Dennis J. O'Driscoll, COL, GS, TXSG, J-1 for Christopher J. Powers, MG, TXSG, Commanding

TXSG Form 23, 7FEB2008Previous editions may not be used

Screening Board Requirement

Board Assigned #1 #2 #3 #4 #5

Additional Information and/or Board Comments & Conditions:

AGTX Form 32

HEADQUARTERS, TEXAS STATE GUARDOFFICER PERSONNEL ACTION COVER SHEET

Award Recommendation

Posn title

DD214/NGB-22 Equiv

TXSG Form 66INS Form I-9Official Photograph

Action Requested Documentation & Requirements ChecklistTXSG Form 3/5

Request Appointment to:

Promotion

Transfer/Reassignment

TXSG Form O1 dtd 7FEB08

TEXAS STATE GUARDOfficer Appointment Checklist

Name: _______________________________________

Unit: ________________________________________

________ TXSG Form 66 – Officer Qualification Record

________ TXSG Form 2 – TXSG Data Base Input Form

________ DD Form 2807-1, Jul 2001, Report of Medical History. Place in an envelope and seal it with Enlistee’s name on the front and the statement “CONFIDENTIAL MEDICAL RECORDS”.

________ Form I-9 U.S. Dept of Justice Employment Eligibility Verification. Passport copy is UNACCEPTABLE. ________ Include a photocopy of a valid Texas Drivers License & Social Security Card on one page. ________ SF85P – NCIC Record Check. (USA Authorization for release of information).

________ Regulation 10-1, 10-2, 10-3 or 10-4 Manning Table (Appendix, Line number, and Slotting showing each assigned member).

________ Evidence of prior military service or high school/college ROTC completion. If applicable, include a copy of DD Form 214 or Discharge Certificate, NGB 22 etc. Former Reservists will provide a copy of DARP 249R or copy of their Honorable Discharge certificate. SF 180 signed form required for all prior service.

________ Highest completed college transcript (unofficial transcript issued to student OK) from certified institution.

________ Evidence of certification or license for Professional Skills Officer Program IAW TXSG Reg 600-10, para 2-3. Eligibility for all Officer and Warrant Officer Appointments.Enlistments, Table 2.2 .

________ TXSG Form 3, Order for Officer Personnel Action.

________ A 3/4 length color photograph from head to mid calf at the RIGHT oblique. Polaroids are unacceptable. (Digital photographs can be e-mailed to david.hathaway@txsg.state.tx.us)

INSTRUCTIONS FOR ATTACHED FORMS

1. All entries on application documents will be typewritten or printed in BLACK ink only. All signatures will be in BLACKink and should be in the following method: First name, Middle name, and Last name.

2. Dates will be entered using the military date system. For example, the fifth of July 2008 would be written: 5 JUL 2008, NOT5/7/2008.

3. Civilian education entries should include only high school, trade school, colleges and universities. ROTC credit is to be listedin this space.

4. Prior Military service entries will show all prior military service including TXSG service. Periods of service will be groupedinto major branches of the Armed forces, i.e., TXSG, US Army, USAF, USMC, NAVY, etc.

5. Unit commander must complete and sign the background certification in Section II of Form TSG Form 66 only after NCIC isreturned "Qualified".

6. Officers will not be administered the Oath in Section III of Form TXSG form 66. It should be noted that the effective date ofthe appointment will be the date the the PASB appoints the Officer and the oath is administered and not signed until theNCIC check has been cleared.

OFFICER QUALIFICATION RECORD

SECTION I - APPLICATION FOR APPOINTMENT

1. NAME OF APPLICANT (Last, First Middle) 2. SOCIAL SECURITY NUMBER

3. RESIDENTIAL ADDRESS (Street, City, State, Zip) 4. HOME PHONE NUMBER

( ) -

5. NAME OF EMPLOYER (Include Self Employment) 6. JOB TITLE 7. BUSINESS PHONE NUMBER

( ) -

8. DATE OF BIRTH (Day, Month, Year) 9. CITIZENSHIP 10. SEX 11. HEIGHT 12. WEIGHT 13. BLOOD TYPE

M_______ F_______ IN______

14. COLOR OF EYES 15. COLOR OF HAIR 16. MARITAL STATUS 17. RACE (Ethnic data is maintained in accordance with the requirements of 42 U S C)

[ ] WHITE [ ] BLACK

18. TEXAS STATE GUARD UNIT 19. INITIAL ASSIGNMENT [ ] HISPANIC [ ] AMERICAN INDIAN

[ ] ASIAN AMERICAN [ ] OTHER (SPECIFY) ________________

20. CIVILIAN EDUCATION (List High Schools, Trade Schools & Colleges)

NAME OF SCHOOL LOCATION (City & State) YEAR COMPLETED / # SEM HRS DEGREE OR RATING

21. PRIOR MILITARY SERVICE (List each major period of duty. Non prior service include Texas State Guard service)

Date From Date To Highest Grade Armed Force Duty Assignment Unit

22. MILITARY EDUCATION

TSG FORM 66 REVISED 7FEB2008

COURSE NAME LOCATION YEAR COMPLETED QUALIFICATION (if applicable)

SECTION I - APPLICATION FOR APPOINTMENT (cont.) 23. AWARDS and DECORATIONS (Inclusive of Texas State Guard Awards)

24. Have you ever been arrested? Yes __________ No __________ If yes, provide a list of charges and disposition below:

Charge Date Disposition

I certify that the information in Section I is a true and correct statement of my personal history, educational background and military experience. I request appointment

as a commissioned officer in the Texas State Guard. I authorize any law enforcement agency to release, to an officer of the Texas State Guard, any record of criminal activity

on file concerning me.

Date Signature of Applicant

SECTION II - ACTION BY THE MSC On this __________ day of ____________________ 20 _____, the applicant appeared before the Screening Board and through personal interview and examination of educational and military records, we, the members of this board, verify the validity of the application, and recommend the applicant for appointment as a commissioned

officer of the Texas State Guard. Recommend initial appointment in the rank of ____________________________ . PRINTED NAME AND GRADE SIGNATURE

SECTION III - OATH OF OFFICE

I, _______________________________________, do solemnly swear that I will bear true faith and allegiance to the State of Texas and the United States of America, that I will serve them honestly and faithfully against all their enemies whomsoever, and that I will obey the orders of the Governor of Texas, and the orders of the officers appointed over me, according to the laws, rules and articles for the government of the Military Forces of the State of Texas.

Subscribed and sworn before me at ____________________________________, Texas on this ___________day of _____________________ 20__________.

SIGNATURE

SIGNATURE OF OFFICER ADMINISTRERING OATH

PRINTED NAME AND GRADE

SECTION IV - RECORD OF PRIOR SERVICE IN TXSG

TSG Form 66 Revised 7FEB2008

Member Admin : Add New Member - INPUT FORMIMPORTANT: Do NOT use your web browser's Back and Forward buttons to navigate between steps!

To avoid losing data, please use the Previous and Next buttons at the bottom of your wizard.

Enter the new member's basic Contact Information.

LAST Name: SSN:

FIRST Name: DOB:

Middle Name: Address:

Suffix: City:

Home Phone: State/Zip:

Mobile Phone: Home E-Mail:

Add the member's Physical Information below. ALL FIELDS ARE REQUIRED

Gender: Race:

Height: Eye Color:

Weight: Hair Color:

Blood Type:

Add new member's initial rank and date of entry.

Military Type:

Rank Level:

Rank:

Date of Rank

/Initial Entry:

Choose which Unit the member will be assigned to.

First select a Top-Level Unit:

Now select a Subordinate Unit, Detachment or HQ Unit:

TXSG Form 2, Revised 28 February 2007 (Previous Editions of this form are obsolete)

X ALL APPLICABLE BOXES:

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confine-ment or a $10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into acommissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for dischargeand could receive a less than honorable discharge that would affect your future.

REPORT OF MEDICAL HISTORY(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

Form ApprovedOMB No. 0704-0413Expires Aug 31, 2003

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources,gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collectionof information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports(0704-0413), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall besubject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.

1. LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) 2. SOCIAL SECURITY NUMBER 3. TODAY'S DATE (YYYYMMDD)

4.a. HOME ADDRESS (Street, Apartment No., City, State, and ZIP Code)

b. HOME TELEPHONE (Include Area Code)

5. EXAMINING LOCATION AND ADDRESS (Include ZIP Code)

Army

Navy

Marine Corps

Air Wing

Active Duty

Reserve

c. PURPOSE OF EXAMINATION

Enlistment

Commission

Retention

Separation

Medical Board

Retirement

U.S. Service Academy

ROTC Scholarship Program

Other (Specify)

7.a. POSITION (Title, Grade, Component)

b. USUAL OCCUPATION

8. CURRENT MEDICATIONS (Prescription and Over-the-counter) 9. ALLERGIES (Including insect bites/stings, foods, medicine or other substance)

HAVE YOU EVER HAD OR DO YOU NOW HAVE: YES NO

c. Coughed up blood d. Asthma or any breathing problems related to exercise, weather, pollens, etc.

e. Shortness of breath

f. Bronchitis

YES NO

11.a. Severe tooth or gum trouble

b. Thyroid trouble or goiter

c. Eye disorder or trouble

d. Ear, nose, or throat trouble

e. Loss of vision in either eye

f. Worn contact lenses or glasses

g. A hearing loss or wear a hearing aid

c. Recurrent back pain or any back problem

d. Numbness or tingling

e. Loss of finger or toe

b. Recent unexplained gain or loss of weight

c. Currently in good health (If no, explain in Item 29 on Page 2.)

d. Tumor, growth, cyst, or cancer

k. Any need to use corrective devices such as prosthetic devices, knee brace(s), back support(s), lifts or orthotics, etc. l. Bone, joint, or other deformity

m. Plate(s), screw(s), rod(s) or pin(s) in any bone

n. Broken bone(s) (cracked or fractured)

DD FORM 2807-1, JUL 2001 DoD exception to SF 93 approved by ICMR, August 3, 2000.PREVIOUS EDITION MAY BE USED UNTIL FEBRUARY 1, 2002.

13.a. Frequent indigestion or heartburn

b. Stomach, liver, intestinal trouble, or ulcer

14.a. Adverse reaction to serum, food, insect stings or medicine

l. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)

j. Any knee or foot surgery including arthroscopy or the use of a scope to any bone or joint

12.a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)

b. Arthritis, rheumatism, or bursitis

h. Surgery to correct vision (RK, PRK, LASIK, etc.)

j. Sinusitis

k. Hay fever

l. Chronic or frequent colds

g. Wheezing or problems with wheezing

i. A chronic cough or cough at night

h. Been prescribed or used an inhaler

10.a. Tuberculosis

b. Lived with someone who had tuberculosis

Page 1 of 3 Pages

c. Gall bladder trouble or gallstones

d. Jaundice or hepatitis (liver disease)

e. Rupture/hernia

g. Skin diseases (e.g. acne, eczema, psoriasis, etc.)

h. Frequent or painful urination

i. High or low blood sugar

j. Kidney stone or blood in urine

k. Sugar or protein in urine

f. Rectal disease, hemorrhoids or blood from the rectum

6.a. SERVICE

12. (Continued)

f. Foot trouble (e.g., pain, corns, bunions, etc.)

g. Impaired use of arms, legs, hands, or feet

h. Swollen or painful joint(s)

i. Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.)

PRIVACY ACT STATEMENTAUTHORITY: 10 USC 504, 505, 507, 532, 978, 1201, 1202, and 4346; and E.O. 9397.PRINCIPAL PURPOSE(S): To obtain medical data for determination of medical fitness for enlistment, induction, appointment and retention for applicants andmembers of the Armed Forces. The information will also be used for medical boards and separation of Service members from the Armed Forces.ROUTINE USE(S): None.DISCLOSURE: Voluntary; however, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enterthe Armed Forces. For an Armed Forces member, failure to provide the information may result in the individual being placed in a non-deployable status.

b. COMPONENT

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 on Page 2.

a. Sensitivity to chemicals, dust, sunlight, etc.

b. Inability to perform certain motions

c. Inability to stand, sit, kneel, lie down, etc.

d. Other medical reasons (If yes, give reasons.)

19. Have you been refused employment or been unable to hold a job or stay in school because of:

28. Have you ever been denied life insurance?

22. Have you ever had, or have you been advised to have any operations or surgery? (If yes, describe and give age at which occurred.)

21. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

20. Have you ever been treated in an Emergency Room? (If yes, for what?)

24. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.)

25. Have you ever been rejected for military service for any reason? (If yes, give date and reason for rejection.)

26. Have you ever been discharged from military service for any reason? (If yes, give date, reason, and type of discharge; whether honorable, other than honorable, for unfitness or unsuitability.)

27. Have you ever received, is there pending, or have you ever applied for pension or compensation for any disability or injury? (If yes, specify what kind, granted by whom, and what amount, when, why.)

23. Have you ever had any illness or injury other than those already noted? (If yes, specify when, where, and give details.)

29. EXPLANATION OF "YES" ANSWER(S) (Describe answer(s), give date(s) of problem, name of doctor(s) and/or hospital(s), treatment given and current medical status.)

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL PERSONNEL ONLY."

DD FORM 2807-1, JUL 2001 Page 2 of 3 Pages

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER

b. Habitual stammering or stuttering

c. Loss of memory or amnesia, or neurological symptoms

17.a. Nervous trouble of any sort (anxiety or panic attacks)

e. Received counseling of any type

d. Frequent trouble sleeping

g. Been evaluated or treated for a mental condition

h. Attempted suicide

i. Used illegal drugs or abused prescription drugs

f. Depression or excessive worry

18. FEMALES ONLY. Have you ever had or do you now have:

a. Treatment for a gynecological (female) disorder

b. A change of menstrual pattern

c. Any abnormal PAP smears

d. First day of last menstrual period (YYYYMMDD)

e. Date of last PAP smear (YYYYMMDD)

YES NO YES NO

15.a. Dizziness or fainting spells

b. Frequent or severe headache

c. A head injury, memory loss or amnesia

d. Paralysis

e. Seizures, convulsions, epilepsy or fits

f. Car, train, sea, or air sickness

g. A period of unconsciousness or concussion

h. Meningitis, encephalitis, or other neurological problems

c. Pain or pressure in the chest

d. Palpitation, pounding heart or abnormal heartbeat

e. Heart trouble or murmur

f. High or low blood pressure

b. Prolonged bleeding (as after an injury or tooth extraction, etc.)

16.a. Rheumatic fever

Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 29 below.HAVE YOU EVER HAD OR DO YOU NOW HAVE:

a. COMMENTS

b. TYPED OR PRINTED NAME OF EXAMINER (Last, First, Middle Initial) d. DATE SIGNED (YYYYMMDD)

c. SIGNATURE

DD FORM 2807-1, JUL 2001 Page 3 of 3 Pages

LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX) SOCIAL SECURITY NUMBER

30. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician/practitioner shall comment on all positive answers in questions 10 - 29. Physician/practitioner may develop by interview any additional medical history deemed important, and record any significant findings here.)

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the U.S.) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination.

All employees, citizens and noncitizens, hired after November 6, 1986 and working in the United States must complete a Form I-9.

OMB No. 1615-0047; Expires 06/30/08

Preparer/Translator Certification. The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his/her own. However, the employee must still sign Section 1 personally.

Form I-9 (Rev. 06/05/07) N

Please read all instructions carefully before completing this form. Instructions

When Should the Form I-9 Be Used?

What Is the Purpose of This Form?

The purpose of this form is to document that each new employee (both citizen and non-citizen) hired after November 6, 1986 is authorized to work in the United States.

Section 2, Employer: For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers or farm labor contractors.

Filling Out the Form I-9

document(s) within three business days, they must present a receipt for the application of the document(s) within three business days and the actual document(s) within ninety (90) days.  However, if employers hire individuals for a duration of less than three business days, Section 2 must be completed at the time employment begins. Employers must record:

Section 1, Employee: This part of the form must be completed at the time of hire, which is the actual beginning of employment. Providing the Social Security number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.

1. Document title;2. Issuing authority;3. Document number;4. Expiration date, if any; and 5. The date employment begins.

Employers must sign and date the certification. Employees  must present original documents. Employers may, but are not required to, photocopy the document(s) presented. These photocopies may only be used for the verification process and must be retained with the Form I-9. However, employers are still responsible for completing and retaining the Form I-9.

Employers must complete Section 2 by examining evidence of identity and employment eligibility within three (3) business days of the date employment begins. If employees are authorized to work, but are unable to present the required

Section 3, Updating and Reverification: Employers must complete Section 3 when updating and/or reverifying the Form I-9.   Employers must reverify employment eligibility of their employees on or before the expiration date recorded in Section 1.  Employers CANNOT specify which document(s) they will accept from an employee.

B. If an employee is rehired within three (3) years of the date this form was originally completed and the employee is still eligible to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

C. If an employee is rehired within three (3) years of the date this form was originally completed and the employee's work authorization has expired or if a  current employee's work authorization is about to expire (reverification), complete Block B and:

A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

1. Examine any document that reflects that the employee is authorized to work in the U.S. (see List A or C);

2. Record the document title, document number and expiration date (if any) in Block C, and

3. Complete the signature block.

EMPLOYERS MUST RETAIN COMPLETED FORM I-9 PLEASE DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

Form I-9 (Rev. 06/05/07) N Page 2

To order USCIS forms, call our toll-free number at 1-800-870- 3676. Individuals can also get USCIS forms and information on immigration laws, regulations and procedures by telephoning our National Customer Service Center at 1-800- 375-5283 or visiting our internet website at www.uscis.gov.

USCIS Forms and Information

What Is the Filing Fee?

There is no associated filing fee for completing the Form I-9. This form is not filed with USCIS or any government agency. The Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below.

The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).

Privacy Act Notice

This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by officials of U.S. Immigration and Customs Enforcement, Department of Labor and Office of Special Counsel for Immigration Related Unfair Employment Practices.

Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

We try to create forms and instructions that are accurate, can be easily understood and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about this form, and completing the form, 9 minutes; 2) assembling and filing (recordkeeping) the form, 3 minutes, for an average of 12 minutes per response. If you have comments regarding the accuracy of this burden estimate, or suggestions for making this form simpler, you can write to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529. OMB No. 1615-0047.

Paperwork Reduction Act

A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions  must be available to all employees completing this form. Employers must retain completed Forms I-9 for three (3) years after the date of hire or one (1) year after the date employment ends, whichever is later.

Photocopying and Retaining the Form I-9

The Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.§

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

OMB No. 1615-0047; Expires 06/30/08

Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins.Print Name: Last First Middle Initial Maiden Name

Address (Street Name and Number) Apt. # Date of Birth (month/day/year)

StateCity Zip Code Social Security #

A lawful permanent resident (Alien #) AA citizen or national of the United States I am aware that federal law provides for

imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

An alien authorized to work until

(Alien # or Admission #)Employee's Signature Date (month/day/year)

Preparer and/or Translator Certification. (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Address (Street Name and Number, City, State, Zip Code)

Print NamePreparer's/Translator's Signature

Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s).

ANDList B List CORList ADocument title:

Issuing authority:

Document #:

Expiration Date (if any):Document #:

Expiration Date (if any):

and that to the best of my knowledge the employee is eligible to work in the United States. (State(month/day/year)employment agencies may omit the date the employee began employment.)

CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on

Print Name TitleSignature of Employer or Authorized Representative

Date (month/day/year)Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

B. Date of Rehire (month/day/year) (if applicable)A. New Name (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility.

Document #: Expiration Date (if any):Document Title:

Section 3. Updating and Reverification. To be completed and signed by employer. 

l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Date (month/day/year)Signature of Employer or Authorized Representative

Form I-9 (Rev. 06/05/07) N

I attest, under penalty of perjury, that I am (check one of the following):

For persons under age 18 who are unable to present a document listed above:

LISTS OF ACCEPTABLE DOCUMENTS

LIST A LIST B LIST C

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

7. Unexpired employment authorization document issued by DHS (other than those listed under List A)

1. Driver's license or ID card issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address

1. U.S. Social Security card issued by the Social Security Administration (other than a card stating it is not valid for employment)

9. Driver's license issued by a Canadian government authority

1. U.S. Passport (unexpired or expired)

2. Certification of Birth Abroad issued by the Department of State (Form FS-545 or Form DS-1350)

3. An unexpired foreign passport with a temporary I-551 stamp

4. An unexpired Employment Authorization Document that contains a photograph

(Form I-766, I-688, I-688A, I-688B)  

3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal

3. School ID card with a photograph

5. An unexpired foreign passport with an unexpired Arrival-Departure Record, Form I-94, bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, if that status authorizes the alien to work for the employer

6.  Military dependent's ID card

4.   Native American tribal document

7. U.S. Coast Guard Merchant Mariner Card

5.   U.S. Citizen ID Card (Form I-197)

8.   Native American tribal document

6. ID Card for use of Resident Citizen in the United States (Form I-179)

10. School record or report card

11. Clinic, doctor or hospital record

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address

Form I-9 (Rev. 06/05/07) N Page 2

4.   Voter's registration card

5.   U.S. Military card or draft record

Documents that Establish Both Identity and Employment

Eligibility

Documents that Establish Identity

Documents that Establish Employment Eligibility

OR AND

INSTRUCTION AND INFORMATION SHEET FOR SF 180, REQUEST PERTAINING TO MILITARY RECORDS

1. Information needed to locate records. Certain identifying information is necessary to determine the location of an individual's record of military service. Please try to answer each item on the SF 180. If you do not have and cannot obtain the information for an tem, show "NA," meaning the information is "not available." Include as much of the requested information as you can. i

2. Restrictions on release of information. Release of information is subject to restrictions imposed by the military services consistent with Department of Defense regulations and the provisions of the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The service member (either past or present) or the member's legal guardian has access to almost any information contained in that member's own record. An authorization signature, of the service member or the member's legal guardian, is needed in Section III of the SF180. Others requesting information from military personnel/health records must have the release authorization in Section III of the SF 180 signed by the member or legal guardian, but if the appropriate signature cannot be obtained, only limited types of information can be provided. If the former member is deceased, surviving next of kin may, under certain circumstances, be entitled to greater access to a deceased veteran's records than a member of the public. The next of kin may be any of the following: unremarried surviving spouse, father, mother, son, daughter, sister, or brother. Employers and others needing proof of military service are expected to accept the information shown on documents issued by the military service departments at the time a service member is separated. 3. Where reply may be sent. The reply may be sent to the member or any other address designated by the member or other authorized requester. 4. Charges for service. There is no charge for most services provided to members or their surviving next of kin. A nominal fee is charged for certain types of service. In most instances service fees cannot be determined in advance. If your request involves a ervice fee, you will be notified as soon as that determination is made. s

5. Health and personnel records. Health records of persons on active duty are generally kept at the local servicing clinic, and usually are available from the Department of Veterans Affairs a week or two after the last day of active duty. (See page 2 of SF180 or record locations/addresses.) f

6. Records at the National Personnel Records Center. Note that it takes at least three months, and often up to seven, for the file to reach the National Personnel Records Center in St. Louis after the military obligation has ended (such as by discharge). If only a short time has passed, please send the inquiry to the address shown for active or current reserve members. Also, if the person has only been released from active duty but is still in a reserve status, the personnel record will stay at the location specified for reservists. A person can retain a reserve obligation for several years, even without attending meetings or receiving annual training. See page 2 of SF180 for record locations/addresses.) (

7. Definitions and abbreviations. DISCHARGED -- the individual has no current military status; HEALTH -- Records of physical examinations, dental treatment, and outpatient medical treatment received while in a duty status (does not include records of reatment while hospitalized); TDRL – Temporary Disability Retired List. t

8. Service completed before World War I. National Archives Trust Fund (NATF) forms must be used to request these records.

btain the forms by e-mail from inquire@nara.gov or write to the Code 6 address on page 2 of the SF 180. O

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION The following information is provided in accordance with 5 U.S.C. 552a(e)(3) and applies to this form. Authority for collection of the information is 44 U.S.C. 2907, 3101, and 3103, and Public Law 104-134 (April 26, 1996), as amended in title 31, section 7701. Disclosure of the information is voluntary. If the requested information is not provided, it may delay servicing your inquiry because the facility servicing the service member's record may not have all of the information needed to locate it. The purpose of the information on this form is to assist the facility servicing the records (see the address list) in locating the correct military service record(s) or information to answer your inquiry. This form is then filed in the requested military service record as a record of disclosure. The form may also be disclosed to Department of Defense components, the Department of Veterans Affairs, the Department of Homeland Security (DHS, U.S. Coast Guard), or the National Archives and Records Administration when the original custodian of the military health and personnel records transfers all or part of those records to that agency. If the service member was a member of the National Guard, the form may also be disclosed to the Adjutant General of the appropriate state, District of Columbia, or Puerto Rico, where he or she served.

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT Public burden reporting for this collection of information is estimated to be five minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS AS INDICATED IN THE ADDRESS LIST ON PAGE 2 OF THE SF 180.

Standard Form 180 (Rev. 10-05) (Page 1) Authorized for local reproduction Prescribed by NARA (36 CFR 1228.168(b)) Previous edition unusable OMB No. 3095-0029 Expires 9/30/2008

To ensure the best possible service, please thoroughly review the accompanying instructions before filling out this form. Please print REQUEST PERTAINING TO MILITARY RECORDS clearly or type. If you need more space, use plain paper.

SECTION I - INFORMATION NEEDED TO LOCATE RECORDS (Furnish as much as possible.) 2. SOCIAL SECURITY NO. 1. NAME USED DURING SERVICE (last, first, and middle) 3. DATE OF BIRTH 4. PLACE OF BIRTH

5. SERVICE , PAST AND PRESENT (For an effective records search, it is important that all service be shown below.) SERVICE NUMBER DATES OF SERVICE CHECK ONE DURING THIS PERIOD

a. ACTIVE SERVICE

b. RESERVE SERVICE

c. NATIONAL GUARD

BRANCH OF SERVICE DATE ENTERED DATE RELEASED OFFICER ENLISTED (If unknown, write “unknown”)

6. IS THIS PERSON DECEASED? If “YES” enter the date of death. 7. IS (WAS) THIS PERSON RETIRED FROM MILITARY SERVICE? NO YESNO YES

SECTION II – INFORMATION AND/OR DOCUMENTS REQUESTED

1. REPORT OF SEPARATION (DD Form 214 or equivalent). This contains information normally needed to verify military service. A copy may be sent to the veteran, the deceased veteran's next of kin, or other persons or organizations if authorized in Section III, below. NOTE: If more than one period of service was performed, even in the same branch, there may be more than one Report of Separation. Be sure to show EACH year that a Report of Separation was issued, for which you need a copy.

An UNDELETED Report of Separation is requested for the year(s)

This normally will be a copy of the full separation document including such sensitive items as the character of separation, authority for separation, reason for separation, reenlistment eligibility code, separation (SPD/SPN) code, and dates of time lost. An undeleted version is ordinarily required to determine eligibility for benefits.

A DELETED Report of Separation is requested for the year(s)

The following information will be deleted from the copy sent: authority for separation, reason for separation, reenlistment eligibility code, separation(SPD/SPN) code, and for separations after June 30, 1979, character of separation and dates of time lost.

2. OTHER INFORMATION AND/OR DOCUMENTS REQUESTED

3. PURPOSE (Optional – An explanation of the purpose of the request is strictly voluntary. Such information may help the agency answering this request to provide the best possible response and will in no way be used to make a decision to deny the request.)

SECTION III - RETURN ADDRESS AND SIGNATURE 1. REQUESTER IS:

Military service member or veteran identified in Section I, above

Next of kin of deceased veteran (relation)

2. SEND INFORMATION/DOCUMENTS TO: (Please print or type. See item 3 on accompanying instructions.)

Name

Street Apt.

City State Zip Code

Legal guardian (must submit copy of court appointment)

Other (specify)

3. AUTHORIZATION SIGNATURE REQUIRED (See item 2 on accompanying instructions.) I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the information in this Section III is true and correct.

Signature (Please do not print.)

( )Date of this request Daytime phone

Email address

** This form is available at http://www.archives.gov/research/order/standard-form-180.pdf on the National Archives and Records Administration (NARA) web site.**

Standard Form 180 (Rev. 10-05) (Page 2) Authorized for local reproduction Prescribed by NARA (36 CFR 1228.168(b)) Previous edition unusable OMB No. 3095-0029 Expires 9/30/2008

LOCATION OF MILITARY RECORDSThe various categories of military service records are described in the chart below. For each category there is a code number which indicates the address at the bottom of the page to which this request should be sent. Please refer to the Instruction and Information Sheet accompanying this form as needed.

ADDRESS CODE BRANCH CURRENT STATUS OF SERVICE MEMBER Personnel

Record Health Record

Discharged, deceased, or retired before 5/1/1994 14 14 Discharged, deceased, or retired 5/1/1994 – 9/30/2004 14 11 Discharged, deceased, or retired on or after 10/1/2004 1 11 Active (including National Guard on active duty in the Air Force), TDRL, or general officers retired with pay 1 Reserve, retired reserve in nonpay status, current National Guard officers not on active duty in the Air Force, or National Guard released from active duty in the Air Force 2

AIR FORCE

Current National Guard enlisted not on active duty in the Air Force 13 Discharge , deceased, or retired before 1/1/1898 6 Discharged, deceased, or retired 1/1/1898 – 3/31/1998 14 14 Discharged, deceased, or retired on or after 4/1/1998 14 11

COAST GUARD

Active, reserve, or TDRL 3 Discharged, deceased, or retired before 1/1/1905 6 Discharged, deceased, or retired 1/1/1905 – 4/30/1994 14 14 Discharged, deceased, or retired 5/1/1994 – 12/31/1998 14 11 Discharged, deceased, or retired on or after 1/1/1999 4 11 Individual Ready Reserve or Fleet Marine Corps Reserve 5

MARINE CORPS

Active, Selected Marine Corps Reserve, TDRL 4 Discharged, deceased, or retired before 11/1/1912 (enlisted) or before 7/1/1917 (officer) 6 Discharged, deceased, or retired 11/1/1912 – 10/15/1992 (enlisted) or 7/1/1917 – 10/15/1992 (officer) 14 14 Discharged, deceased, or retired 10/16/1992 – 9/30/2002 14 11 Discharged, deceased, or retired on or after 10/1/2002 7 11 Reserve; or active duty records of current National Guard members who performed service in the U.S. Army before 7/1/1972 7

Active enlisted (including National Guard on active duty in the U.S. Army) or TDRL enlisted 9 Active officers (including National Guard on active duty in the U.S. Army) or TDRL officers 8 Current National Guard enlisted not on active duty in Army (including records of Army active duty performed after 6/30/1972) 13

ARMY

Current National Guard officers not on active duty in Army (including records of Army active duty performed after 6/30/1972) 12

Discharged, deceased, or retired before 1/1/1886 (enlisted) or before 1/1/1903 (officer) 6 Discharged, deceased, or retired 1/1/1886 – 1/30/1994 (enlisted) or 1/1/1903 – 1/30/1994 (officer) 14 14 Discharged, deceased, or retired 1/31/1994 – 12/31/1994 14 11 Discharged, deceased, or retired on or after 1/1/1995 10 11

NAVY

Active, reserve, or TDRL 10 PHS Public Health Service - Commissioned Corps officers only 15

ADDRESS LIST OF CUSTODIANS (BY CODE NUMBERS SHOWN ABOVE) – Where to write/send this form

1 Air Force Personnel Center HQ AFPC/DPSRP 550 C Street West, Suite 19 Randolph AFB, TX 78150-4721

6

National Archives & Records Administration Old Military and Civil Records (NWCTB-Military) Textual Services Division 700 Pennsylvania Ave., N.W. Washington, DC 20408-0001

11 Department of Veterans Affairs Records Management Center P.O. Box 5020 St. Louis, MO 63115-5020

2 Air Reserve Personnel Center /DSMR HQ ARPC/DPSSA/B 6760 E. Irvington Place, Suite 4600 Denver, CO 80280-4600

7 U.S. Army Human Resources Command ATTN: AHRC-PAV-V 1 Reserve Way St. Louis, MO 63132-5200

12 Army National Guard Readiness Center NGB-ARP 111 S. George Mason Dr. Arlington, VA 22204-1382

3 Commander, CGPC-adm-3 USCG Personnel Command 4200 Wilson Blvd., Suite 1100 Arlington, VA 22203-1804

8 U.S. Army Human Resources Command ATTN: AHRC-MSR 200 Stovall Street Alexandria, VA 22332-0444

13 The Adjutant General (of the appropriate state, DC, or Puerto Rico)

4

Headquarters U.S. Marine Corps Personnel Management Support Branch (MMSB-10) 2008 Elliot Road Quantico, VA 22134-5030

9 Commander USAEREC ATTN: PCRE-F 8899 E. 56th St. Indianapolis, IN 46249-5301

14 National Personnel Records Center (Military Personnel Records) 9700 Page Ave. St. Louis, MO 63132-5100

5 Marine Corps Reserve Support Command (Code MMI) 15303 Andrews Road Kansas City, MO 64147-1207

10 Navy Personnel Command (PERS-313C1) 5720 Integrity Drive Millington, TN 38055-3130

15 Division of Commissioned Corps Officer Support ATTN: Records Officer 1101 Wooton Parkway, Plaza Level, Suite 100 Rockville, MD 20852

Texas State Guard Personnel Actions Request – O1 thru O3/WO1 thru CW3Order Number: 2008-______-___ __________________ Date:__________

Julian Date – unit action number Texas State Guard__________________

_______, Texas_________________________________________________________________________Last, First, Middle Initial Social Security Number Present Rank if applicable

Member data to be completed by current Personnel Officer.DOIE ________DOR___________ Prior Svc Branch ________ Rank _____ Total PS Years Served _____DOB ________ Current Weight ______lbs Current Height ___________TIS (TXSG) ______yrs _____mos

Military Education completed: IET BOT OBC OAC C&GC: 50% 100% FEMA Course completions: 100 200 275 546 547 700 800 GDEM: ___ ___ ___ _____________________________________ date_________Certifying Signature of Unit Personnel Officer

Current Mailing Address __________________________________________, __________TX __________Street Address or PO Box City Zipcode

You are recommended for [ ] Appointment [ ] Promotion [ ] Transfer [ ] Reassignment [ ] Discharge

Recommended Rank ___________/ ______ Transferred/Reassigned to ____________, __________TX Unit Designation City

CDR Letter of Recommendation is attached for promotion recommendation.Request for Waiver of _________________is required for this action and/or Letter of Recommendation is attached.

Explain what is being waivedNew position title _______________________Gaining Unit ______________, __________TX IAW 10-1, 10-2, 10-3 or 10-4 Unit Designation City Honorably Discharged for reason:

IAW TXSG Reg 600-10 para 7-5.________________________________effective the date of this request.

This member [ ] is [ ] is not recommended for re-appointment in the TXSG in the future.

{ }Concur { }Nonconcur. ___________________date_______ Signature of CDR at ASG/Bn/Det/MedGrp

{ }Concur { }Nonconcur. _________________________________date____________ Signature of Commander at Regt/Win/Bde

}Headquarters, Texas State Guard FOR THE COMMANDER:

{ }Approved { }Disapproved by Personnel Actions Screening Board

{ }Returned With Out Action (RWOA) ____________________date_____Reason: __________________________ J1 Personnel Officer, TXSG

{ }Approved { }Disapproved ____________________date_____ Chief of Staff, TXSG

Order for O1 thru O3/WO1 thru CW3 Personnel Action TXSG Form 3CoGrade dtd 7FEB2008 (All previous editions are obsolete)

Texas State Guard Personnel Actions Request – O4 thru O7/CW4 thru CW5Order Number: 2008-______-___ __________________ Date:__________

Julian Date – unit action number Texas State Guard__________________

_______, Texas_________________________________________________________________________Last, First, Middle Initial Social Security Number Present Rank if applicable

Member data to be completed by current Personnel Officer.DOIE ________DOR___________ Prior Svc Branch ________ Rank _____ Total PS Years Served _____DOB ________ Current Weight ______lbs Current Height ___________TIS (TXSG) ______yrs _____mos

Military Education completed: OAC C&GC: 50% 100% War College: 50% 100% FEMA Course completions: 100 200 275 546 547 700 800 GDEM: ___ ___ ___ _____________________________________ date_________Certifying Signature of Unit Personnel Officer

Current Mailing Address __________________________________________, __________TX __________Street Address or PO Box City Zipcode

You are recommended for [ ] Appointment [ ] Promotion [ ] Transfer [ ] Reassignment [ ] Discharge

Recommended Rank ___________/ ______ Transferred/Reassigned to ____________, __________TX Unit Designation City

CDR Letter of Recommendation is attached for promotion recommendation.Request for Waiver of _________________is required for this action and/or Letter of Recommendation is attached.

Explain what is being waivedNew position title _______________________Gaining Unit ______________, __________TX IAW 10-1, 10-2, 10-3 or 10-4 Unit Designation City Honorably Discharged for reason:

IAW TXSG Reg 600-10 para 7-5.________________________________effective the date of this request.

This member [ ] is [ ] is not recommended for re-appointment in the TXSG in the future.

{ }Concur { }Nonconcur. ___________________date_______ { }Concur { }Nonconcur _____________________date______ Signature of CDR at ASG/Bn/Det/MedGrp Signature of CDR at Regt/Wing/Bde

{ }Concur { }Nonconcur. _________________________________date____________ Signature of DCG Army Element or Air Division

}Headquarters, Texas State Guard FOR THE COMMANDER:

{ }Approved { }Disapproved by Personnel Actions Screening Board

{ }Returned With Out Action (RWOA) ____________________date_____Reason: __________________________ J1 Personnel Officer, TXSG

{ }Approved { }Disapproved ____________________date_____ Chief of Staff, TXSG

Order for O4 thru O7/CW4 thru CW5 Personnel Action TXSG Form 3FieldGrade dtd 7FEB2008 (All previous editions are obsolete)