Personal Information

Last Name:     First Name:    

Unit:    Rank:    ETS:    MOS: 

Phone:    E-mail Address: 

Height:   Weight:   Last PT Test Date: (See Note#2 at bottom)

Commander's Information

Last Name:    First Name:    Rank: 

Branch (if Army):    Unit Phone: 

Type of Retention Action Needed:

General Information Reenlistment Extension Reclassification Reserve Component

Reenlistment or Extension Processing:

Date you would like to reenlist or extend: 

How many Years or Months?  Years:   Months:

Reason for Extension (if applicable): 

Which option would you like to reenlist for? (if applicable):  Regular Army Reenlistment Option Current Station Stabilization Reenlistment Option Army Training Reenlistment Option CONUS Station of Choice Reenlistment Option Overseas Assignment Reenlistment Option

If you would like to go to another duty station, where would you like to go?

Reenlisting Officer's Signature Block: (Last Name, First Name, Rank and Unit)

Reclassification Processing:

What MOSs would you like to reclassify into? 1st Choice: 2d Choice:

3d Choice:

Note: You need to complete a DA Form 4187 (if you are requesting a reclassification) and send to this office

Note#2: If you are processing for Reenlistment or Extension, you must provide a copy of your last PT test. Please fax a copy to 813-828-6886 DSN:968.

Thank you for taking the time to get started on your future!