APPLICATION FOR ACTIVE DUTY FOR TRAINING, ACTIVE DUTY FOR SPECIAL WORK, TEMPORARY

TOUR OF ACTIVE DUTY, AND ANNUAL TRAINING FOR SOLDIERS OF THE ARMY NATIONAL GUARD

AND U.S. ARMY RESERVE

For use of this form, see AR 135-200; the proponent agency is ODCSPER

ROUTINE USES:

5a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (If

different from permanent home address) (Include ZIP Code)

18. TOTAL YEARS, MONTHS, DAYS OF ACTIVE

FEDERAL SERVICE (AFS) 

17.

EDITION OF MAR 90 IS OBSOLETE

AUTHORITY:

PRINCIPAL PURPOSE:

DISCLOSURE:

DA FORM 1058-R, JUL 93

DATA REQUIRED BY THE PRIVACY ACT OF 1974

10 USC 672(d) and USC 275.

To determine eligibility and schedule individuals for active duty for special work or active duty for training

on requested dates.

To identify the applicant as a Reserve Component member and to issue active duty for special work or

active duty for training orders. The SSN is used to identify the applicant.

Completing this form is mandatory for individuals applying for active duty for special work and active duty

for training. If not completed, you will be ineligible for the requested tour.

PART I - APPLICANT (Read instructions in AR 135-200 before completing this form.)

9. SEX

Male Female

I am I am not drawing a pension, disability compensation,

or retired pay from the U.S. Government.

20. DATES OF ADSW/TTAD/ADT/AT REQUESTED

a. FIRST CHOICE b. SECOND CHOICE

21. To the best of my knowledge and belief, I am physically qualified for active military duty. I was 

19. FOR INDIVIDUAL MOBILIZATION AUGMENTEES ONLY: THIS APPLICATION IS FOR (Check one)

IMA AT ADT in lieu of IMA AT Additional ADT

USAPPC V2.00

2. NAME (Last, First, MI) 3. SSN

4b. HOME TELEPHONE NUMBER (Include area code) 5b. HOME TELEPHONE NUMBER (Include area code) 

4c. BUSINESS TELEPHONE NUMBER (Include area code) 5c. BUSINESS TELEPHONE NUMBER (Include area code) 

6. UNIT OF ASSIGNMENT OR ATTACHMENT 7. GRADE 8. BRANCH

10. DOB 11. MARITAL STATUS 12. NO. OF DEPENDENTS

13. PRIMARY SSI (AOC)/MOS 14. DUTY SSI (AOC)/MOS 15. HEIGHT 16. WEIGHT

NUMBER OF DAYS BEGINNING DATE/TIME

LOCATION 

4a. PERMANENT HOME ADDRESS (Include ZIP Code) 

1. TO (Include ZIP Code) 

22. SIGNATURE

NUMBER OF DAYS BEGINNING DATE/TIME

LOCATION 

DUTY/TRAINING AGENCY DUTY/TRAINING AGENCY 

a. LAST EXAMINED ON b. AT 

23. DATE 
24. REMARKS

I understand that although at the completion of my tour I may be within 2 years of qualifying for an active duty retirement under 

10 USC 1293, 3911, or 3914, it is current Army policy that I will be released from active duty at the completion of my tour unless

continued retention on active duty is considered in the best interest of the Army by the Assistant Secretary of the Army (Manpower

and Reserve Affairs). I hereby consent to my release from active duty at the completion of this tour.

27. PROMOTION

CONSIDERATION CODE 

31. MANDATORY REMOVAL

DATE (Officers)

a. PERIOD OF TRAINING/DUTY

35. List all previous AD, TTAD, AT, ADT, IADT, and ADSW in the previous and current fiscal year showing inclusive dates, purpose

of tours, and HQ or agency to which attached.

(Signature of applicant)

PART II - RECORDS CUSTODIAN

34. PANOGRAPHIC DENTAL X-RAY ON FILE YES NO

FROM TO NO.

DAYS

d. DUTY

PERFORMED

REVERSE, DA FORM 1058-R, JUL 93 USAPPC V2.00

b. TYPE TRAINING/

DUTY

(AD, TTAD, etc.)

c. LOCATION/

INSTALLATION

e. SIGNATURE OF UNIT COMMANDER

29. RYE DATE

26. SECURITY CLEARANCE 28. DATE OF RANK

30. ETS (Enlisted) 32. UIC

33. HIV TEST DATE

f. DATE

25. PAY ENTRY BASIC DATE

c. SIGNATURE

36a. NAME OF RECORDS CUSTODIAN (First, Last, MI) 

d. DATE

b. GRADE