Exhibit_D_DD_Form_1966.pdf

RECORD OF MILITARY PROCESSING - ARMED FORCES OF THE UNITED STATES

(Read Privacy Act Statement and Instructions on back before completing this form.)

OMB No. 0704-0173 OMB approval expires Jul 31, 2014 a collection of information if it does not display a currently valid OMB control number.

A. SERVICE

PROCESSING FOR

B. PRIOR SERVICE:

YES NO

NUMBER OF DAYS:

C. SELECTIVE SERVICE CLASSIFICATION D. SELECTIVE SERVICE REGISTRATION NO.

1. SOCIAL SECURITY NUMBER

SECTION I - PERSONAL DATA

2. NAME (Last, First, Middle Name (and Maiden, if any), Jr., Sr., etc.)

3. CURRENT ADDRESS

(Street, City, County, State, Country, ZIP Code)

4. HOME OF RECORD ADDRESS

(Street, City, County, State, Country, ZIP Code)

5. CITIZENSHIP (X one)

a. U.S. AT BIRTH (If this box is marked, also X (1) or (2))

(1) NATIVE BORN

b. U.S. NATURALIZED

c. U.S. NON-CITIZEN

NATIONAL

d. IMMIGRANT ALIEN (Specify)

e. NON-IMMIGRANT FOREIGN NATIONAL (Specify)

6. SEX (X one)

a. MALE

b. FEMALE

7.a. RACIAL CATEGORY (X one or more)

(1) AMERICAN INDIAN/

ALASKA NATIVE

(2) ASIAN

(3) BLACK OR AFRICAN

AMERICAN

7.b. ETHNIC

CATEGORY

8. MARITAL STATUS (Specify) 9. NUMBER OF DEPENDENTS

10. DATE OF BIRTH

(YYYYMMDD)

11. RELIGIOUS

PREFERENCE

(Optional)

12. EDUCATION

(Yrs/Highest Ed Gr Completed)

13. PROFICIENT IN FOREIGN

LANGUAGE (If Yes, specify.

If No, enter NONE.)

1st 2nd

14. VALID DRIVER'S LICENSE (X one) YES NO (If Yes, list State, number, and expiration date)

15. PLACE OF BIRTH (City, State and Country)

SECTION II - EXAMINATION AND ENTRANCE DATA PROCESSING CODES

(FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SECTION - Go on to Page 2, Question 20.)

16. APTITUDE TEST RESULTS

a. TEST ID b. TEST SCORES AFQT

PERCENTILE

GS AR WK PC MK EI AS MC AO VE

17. DEP ENLISTMENT DATA

a. DATE OF ENLISTMENT - DEP

(YYYYMMDD)

b. PROJ ACTIVE DUTY DATE

(YYYYMMDD)

c. ES d. RECRUITER IDENTIFICATION e. STN ID

g. T-E MOS/AFS h. WAIVER (1)

i. PAY

GRADE

18. ACCESSION DATA

a. DATE OF ENLISTMENT

(YYYYMMDD)

b. ACTIVE DUTY SERVICE DATE

(YYYYMMDD)

c. PAY ENTRY DATE (YYYYMMDD)

f. WAIVER

(1) g. PAY GRADE h. DATE OF GRADE (YYYYMMDD) i. ES j. YRS./HIGHEST

ED GR COMPL

k. RECRUITER IDENTIFICATION l. STN ID n. T-E MOS/AFS o. PMOS/AFS p. YOUTH q. OA

u. TRANSFER TO (UIC)

19. SERVICE

REQUIRED

CODES

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80

81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110

111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140

DD FORM 1966/1, AUG 2011 PREVIOUS EDITION IS OBSOLETE.

(2) BORN ABROAD OF U.S.

PARENT(S)

(2) (3) (4) (5) (6)

(2) (3) (4) (5) (6)

(4)

(5) WHITE

NATIVE HAWAIIAN

OR OTHER PACIFIC

ISLANDER

(1) HISPANIC OR

LATINO

(2) NOT HISPANIC

OR LATINO

ALIEN REGISTRATION NUMBER

(If issued)

The public reporting burden for this collection of information is estimated to average 20 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 collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 (0704-0173). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with

Adobe Designer88.0

f. PEF

j. SVC ANNEX CODES k. MSO (YYWW) l. AD OBLIGA-

TION (YYWW)

d. MSO (YYWW) e. AD/RC OBLIGATION (YYMMWWDD)

r. STATE

GUARD

m. PEF

s. SVC ANNEX CODES t. REPLACES ANNEXES

PRIVACY ACT STATEMENT

DD FORM 1966/1, AUG 2011

AUTHORITY: 10 U.S.C. Sections 136, 504, 505, 12102; 14 U.S.C. Sections 351 and 632; DoDI 1304.2; DoDI 1304.26; AR 601-270; OPNAVINST 1100.4C Ch-1; AFI 36-2003_IP; MCO 1100.75E; COMDTINST M 1100.2E;

AR 601-210; AFPD 36-20; and E.O. 9397, as amended (SSN).

PRINCIPAL PURPOSE(S): The information collected on this form is used to obtain data for use in determining the eligibility of applicants for accession into the Armed Forces and establishing official records for those who are accepted and enlist. Completed forms are covered by recruiting and official military personnel file SORNs maintained by each of the Services.

ROUTINE USE(S): The DoD Blanket Routine Uses found at apply to this collection.

DISCLOSURE: Voluntary. However, failure by an applicant t "optional" may result in a denial of your enlistment application process to keep all records together during the enlistment pro recorded and perform background screening.

WARNING

Information provided by you on this form is FOR OFFICIAL strict compliance with Federal laws and regulations.The inform the United States Government, and it may be consulted throug whenever either favorable or adverse administrative or discipli

YOU CAN BE PUNISHED BY FINE, IMPRISONMENT OR BO

KNOWING AND WILLFUL FALSE STATEMENT ON THIS DO

INSTRUCTIONS

(Read carefully BEFORE filling ou

1. Read Privacy Act Statement above before completing form

2. Type or print LEGIBLY all answers. If the answer is "None" questions may be left blank.

3. Unless otherwise specified, write all dates as 6 digits (with n June 1, 2010 is written 20100601.

Back of Page 1 http://privacy.defense.gov/blanket_uses.shtml o provide the information not annotated as . An applicant's SSN is used during the recruitment cess, ensure testing and results are properly

USE ONLY and will be maintained and used in ation provided by you becomes the property of hout your military service career, particularly nary actions related to you are involved.

TH IF YOU ARE FOUND GUILTY OF MAKING

CUMENT.

t this form.)

or "Not Applicable", so state. "Optional" o spaces or marks) in YYYYMMDD fashion.

DD FORM 1966/2, AUG 2011 Page 2

20. NAME (Last, First, Middle Initial) 21. SOCIAL SECURITY NUMBER

SECTION III - OTHER PERSONAL DATA

22. EDUCATION

a. List all high schools and colleges attended. (List dates in YYYYMM format.)

(1) FROM (2) TO (3) NAME OF SCHOOL (4) LOCATION

(5) GRADUATE

YES NO

b. Have you ever been enrolled in ROTC, Junior ROTC, Sea Cadet Program or Civil Air Patrol?

YES NO

23. MARITAL/DEPENDENCY STATUS AND FAMILY DATA

(If "Yes," explain in Section VI, "Remarks.")

a. Is anyone dependent upon you for support?

b. Is there any court order or judgment in effect that directs you to provide alimony or support for children?

c. Do you have an immediate relative (father, mother, brother, or sister) who: (1) is now a prisoner of war or is missing in action (MIA); or (2) died or became 100% permanently disabled while serving in the Armed Services?

d. Are you the only living child in your immediate family?

24. PREVIOUS MILITARY SERVICE OR EMPLOYMENT WITH THE U.S. GOVERNMENT

(If "Yes," explain in Section VI, "Remarks.")

a. Are you now or have you ever been in any regular or reserve branch of the Armed Forces or in the Army National Guard or Air National Guard?

b. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the Armed Forces of the United States?

c. Are you now or have you ever been a deserter from any branch of the Armed Forces of the United States?

d. Have you ever been employed by the United States Government?

e. Are you now drawing, or do you have an application pending, or approval for: retired pay, disability allowance, severance pay, or a pension from any agency of the government of the United States?

25. ABILITY TO PERFORM MILITARY DUTIES

(If "Yes," explain in Section VI, "Remarks.")

a. Are you now or have you ever been a conscientious objector? (That is, do you have, or have you ever had, a firm, fixed, and sincere objection to participation in war in any form or to the bearing of arms because of religious belief or training?)

b. Have you ever been discharged by any branch of the Armed Forces of the United States for reasons pertaining to being a conscientious objector?

c. Is there anything which would preclude you from performing military duties or participating in military activities whenever necessary (i.e., do you have any personal restrictions or religious practices which would restrict your availability)?

26. DRUG USE AND ABUSE (If "Yes," explain in Section VI, "Remarks.") Have you ever tried, used, sold, supplied, or possessed any narcotic (to include heroin or cocaine), depressant (to include quaaludes), stimulant, hallucinogen (to include LSD or PCP), or cannabis (to include marijuana or hashish), or any mind-altering substance (to include glue or paint), or anabolic steroid, except as prescribed by a licenced physician?

DD FORM 1966/3, AUG 2011 Page 3

27. NAME (Last, First, Middle Initial) 28. SOCIAL SECURITY NUMBER

31. CERTIFICATION OF WITNESS

a. I certify that I have witnessed the applicant's signature above and that I have verified the data in the documents required as prescribed by my directives. I further certify that I have not made any promises or guarantees other than those listed and signed by me. I understand my liability to trial by courts-martial under the Uniform Code of Military Justice should I effect or cause to be effected the enlistment of anyone known by me to be ineligible for enlistment.

b. TYPED OR PRINTED NAME (Last, First, Middle Initial)

e. SIGNATUREc. PAY

GRADE

d. RECRUITER I.D. f. DATE SIGNED

(YYYYMMDD)

32. SPECIFIC OPTION/PROGRAM ENLISTED FOR, MILITARY SKILL, OR ASSIGNMENT TO A GEOGRAPHICAL AREA GUARANTEES

a. SPECIFIC OPTION/PROGRAM ENLISTED FOR (Completed by Guidance Counselor, MEPS Liaison NCO, etc., as specified by sponsoring service.)

(Use clear text English.)

b. I fully understand that I will not be guaranteed any specific military skill or assignment to a geographic area except as shown in Item 32.a. above and annexes attached to my Enlistment/Reenlistment Document (DD Form 4).

c. APPLICANT'S

INITIALS

33. CERTIFICATION OF RECRUITER OR ACCEPTOR

a. I certify that I have reviewed all information contained in this document and, to the best of my judgment and belief, the applicant fulfills all legal policy requirements for enlistment. I accept him/her for enlistment on behalf of the United States (Enter Branch of Service) and certify that I have not made any promises or guarantees other than those listed in Item 32.a.

above. I further certify that service regulations governing such enlistments have been strictly complied with and any waivers required to effect applicant's enlistment have been secured and are attached to this document.

b. TYPED OR PRINTED NAME (Last, First, Middle Initial)

e. SIGNATUREc. PAY

GRADE

d. RECRUITER I.D. OR

ORGANIZATION

f. DATE SIGNED

(YYYYMMDD)

SECTION V - RECERTIFICATION

34. RECERTIFICATION BY APPLICANT AND CORRECTION OF DATA AT THE TIME OF ACTIVE DUTY ENTRY

a. I have reviewed all information contained in this document this date. That information is still correct and true to the best of my knowledge and belief. If changes were required, the original entry has been marked "See Item 34" and the correct information is provided below.

b. ITEM NUMBER c. CHANGE REQUIRED

d. APPLICANT e. WITNESS

(1) SIGNATURE (2) DATE SIGNED

(YYYYMMDD)

(1) TYPED OR PRINTED NAME (Last, First, Middle Initial)

(3) SIGNATURE(2) RANK/

GRADE

SECTION IV - CERTIFICATION

29. CERTIFICATION OF APPLICANT (Your signature in this block must be witnessed by your recruiter.)

a. I certify that the information given by me in this document is true, complete, and correct to the best of my knowledge and belief.

I understand that I am being accepted for enlistment based on the information provided by me in this document; that if any of the information is knowingly false or incorrect, I could be tried in a civilian or military court and could receive a less than honorable discharge which could affect my future employment opportunities.

b. TYPED OR PRINTED NAME (Last, First, Middle Initial)

c. SIGNATURE d. DATE SIGNED (YYYYMMDD)

30. DATA VERIFICATION BY RECRUITER (Enter description of the actual documents used to verify the following items.)

a. NAME (X one)

(1) BIRTH CERTIFICATE

(2) OTHER (Explain)

b. AGE (X one)

(1) BIRTH CERTIFICATE

(2) OTHER (Explain)

c. CITIZENSHIP (X one)

(1) BIRTH CERTIFICATE

(2) OTHER (Explain)

d. SOCIAL SECURITY NUMBER (SSN) (X one)

(1) SSN CARD

(2) OTHER (Explain)

e. EDUCATION (X one)

(1) DIPLOMA

(2) OTHER (Explain)

f. OTHER DOCUMENTS USED

SECTION VI - REMARKS

(Specify item(s) being continued by item number. Continue on separate pages if necessary.)

DD FORM 1966/5

ATTACHED? (X one)

YES

NO

DD FORM 1966/4, AUG 2011 Page 4

35. NAME (Last, First, Middle Initial) 36. SOCIAL SECURITY NUMBER

SECTION VII - STATEMENT OF NAME FOR OFFICIAL MILITARY RECORDS

37. NAME CHANGE.

If the preferred enlistment name (name given in Item 2) is not the same as on your birth certificate, and it has not been changed by legal procedure prescribed by state law, and it is the same as on your social security number card, complete the following:

a. NAME AS SHOWN ON BIRTH CERTIFICATE b. NAME AS SHOWN ON SOCIAL SECURITY NUMBER CARD

c. I hereby state that I have not changed my name through any court or other legal procedure; that I prefer to use the name of by which I am known in the community as a matter of convenience and with no criminal intent. I further state that I am the same person as the person whose name is shown in Item 2.

d. APPLICANT

e. WITNESS

(1) SIGNATURE (2) DATE SIGNED

(YYYYMMDD)

(1) TYPED OR PRINTED NAME (Last, First, Middle Initial) (3) SIGNATURE(2) PAY GRADE

DD FORM 1966/5, AUG 2011 Page 5

38. NAME (Last, First, Middle Initial) 39. SOCIAL SECURITY NUMBER

40. PARENT/GUARDIAN STATEMENT(S) (Line out portions not applicable)

a. I/we certify that (Enter name of applicant) has no other legal guardian other than me/us and I/we consent to his/her enlistment in the United States (Enter Branch of Service)

b. FOR ENLISTMENT IN A RESERVE COMPONENT.

I/we understand that, as a member of a reserve component, he/she must serve minimum periods of active duty for training unless excused by competent authority. In the event he/she fails to fulfill the obligations of his/her reserve enlistment, he/she may be recalled to active duty as prescribed by law. I/we further understand that while he/she is in the ready reserve, he/she may be ordered to extended active duty in time of war or national emergency declared by the Congress or the President or when otherwise authorized by law, and may be required upon order to serve in combat or other hazardous situations.

USE THIS DD FORM 1966 PAGE ONLY IF EITHER SECTION APPLIES TO THE APPLICANT'S RECORD OF MILITARY PROCESSING.

SECTION VIII - PARENTAL/GUARDIAN CONSENT FOR ENLISTMENT

I/we acknowledge/understand that he/she may be required upon order to serve in combat or other hazardous situations. I/we certify that no promises of any kind have been made to me/us concerning assignment to duty, training, or promotion during his/her enlistment as an inducement to me/us to sign this consent. I/we hereby authorize the Armed Forces representatives concerned to perform medical examinations, other examinations required, and to conduct records checks to determine his/her eligibility. I/we relinquish all claim to his/her service and to any wage or compensation for such service. I/we authorize him/her to be transported unsupervised to/from the Military Entrance Processing Station via public conveyance and to stay unsupervised at a government contracted hotel facility.

(1) TYPED OR PRINTED NAME (Last, First, Middle Initial) (2) SIGNATURE (3) DATE SIGNED

(YYYYMMDD)

c. PARENT

(1) TYPED OR PRINTED NAME (Last, First, Middle Initial) (2) SIGNATURE (3) DATE SIGNED

(YYYYMMDD)

d. WITNESS

(1) TYPED OR PRINTED NAME (Last, First, Middle Initial) (2) SIGNATURE (3) DATE SIGNED

(YYYYMMDD)

e. PARENT

(1) TYPED OR PRINTED NAME (Last, First, Middle Initial) (2) SIGNATURE (3) DATE SIGNED

(YYYYMMDD)

f. WITNESS

41. VERIFICATION OF SINGLE SIGNATURE CONSENT