HT: _____ WT: _____ HT/WT meet USMC standards: Yes/No if no, BFT% _____

PFT score: _____ Class: _____ Date: __________

SNM has/has not completed the required PME for his grade: Yes/No

Signature/Date ___________________________________________

SNM is / is not pending legal action.

Signature/Date ___________________________________________

SNM is / is not medically qualified for reenlistment/extension. Physical Date: __________

SNM is / is not pending a medical board.

SNM is / is not on limited duty.

SNM does / does not have normal color vision.

Signature/Date ___________________________________________

SNM is / is not dental qualified for reenlistment/extension. Class: _____ Date: _________

SNM has / has not completed Level II/Level III/Alcohol Rehabilitation Treatment in the last 12 months.

Signature/Date ___________________________________________

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Signature/Date ___________________________________________

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Signature/Date ___________________________________________

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Signature/Date ___________________________________________
 

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