Data required by the privacy act of 1974




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APPLICATION FOR ACTIVE DUTY FOR TRAINING, ACTIVE DUTY FOR SPECIAL WORK, TEMPORARY TOUR OF ACTIVE DUTY, ANNUAL TRAINING, AND FULL-TIME NATIONAL GUARD DUTY FOR SPECIAL WORK FOR SOLDIERS OF THE ARMY NATIONAL GUARD



For use of this form, see NGR 37-111 (draft); the proponent agency is NGB-ARM
DATA REQUIRED BY THE PRIVACY ACT OF 1974



AUTHORITY:
PRINCIPAL PURPOSE:

ROUTINE USES:

DISCLOSURE:




10 USC 12301(d) / 32 USC 502(f)
To determine eligibility and schedule individuals for active duty for special work, Temporary Tours of Active Duty, full-time National Guard duty for special work, active duty for training or additional annual training on requested dates.

To identify the applicant as a Reserve Component member and to issue active duty

for special work for active duty for training orders.
Completing this form is mandatory for individuals applying for active duty for special work or active duty for training. If not completed, you will not be eligible for the requested tour.

PART 1 – APPLICANT (Read instructions in NGR 37-111 (draft) before completing this form.)

  1. TO (Include ZIP code)


  1. NAME : (Last, First, MI)




  1. SSN




4a. PERMANENT HOME ADDRESS (Include ZIP code)



5a. ADDRESS FROM WHICH YOU WILL REPORT FOR DUTY (if different from permanent home address) (Include ZIP code)


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)


  1. UNIT OF ASSIGNMENT OR ATTACHMENT



  1. GRADE




  1. BRANCH/MOS




9. SEX


 M F

10. D. O. B.


11. MARITAL STATUS


12. NO. OF DEPENDENTS


13. PRIMARY SSI (AOC)/MOS


14. DUTY SSI (AOC)/MOS


15. HEIGHT


16. WEIGHT

17.  I am  I am not


Drawing a pension, disability compensation, or retired pay from the U. S. Government




18. TOTAL YEARS, MONTHS, DAYS OF ACTIVE FEDERAL SERVICE (AFS)



19. NAME, RANK AND SIGNATURE OF NGB/STATE/TERRITORY HUMAN RESOURCE OFFICER (or AGR TOUR MANAGER) VERIFYING DATA IN BLOCK 18.


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

  1. FIRST CHOICE

  1. SECOND CHOICE

NUMBER OF DAYS



BEGINNING DATE/TIME


NUMBER OF DAYS


BEGINNING DATE/TIME


LOCATION


LOCATION



DUTY/TRAINING AGENCY

DUTY/TRAINING AGENCY


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

a. LAST EXAMINED ON


b. AT

  1. SIGNATURE



23. DATE


ARNG Form 1058-R, JUL 02





  1. 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 FTNGD at the completion of my tour unless I am offered a follow-on tour as approved by CNGB. I hereby waive sanctuary and consent to being ordered to FTNGD for a period indicated on my order and consent to my release from FTNGD at the completion of this tour.”



X .

(Signature of applicant)

(THIS ACTION WILL NOT BE APPROVED WITHOUT THE SOLDIER’S SIGNATURE IN THIS BLOCK)



.

ADDITIONAL REMARKS:



  • Identify Break in Service. Used to verify last 31-Day Break in Active Federal Service (AFS).



 (a) Beginning Date of the most recent break in AFS of 31 days or more: .

 (b) Ending Date of the most recent break in AFS of 31 days or more: _________________.

 (c) Numbers of Days ______________.


  • Type of Duty Code (TDC) to be used in fund cite: .



PART II – RECORDS CUSTODIAN


  1. PAY ENTRY BASIC DATE




  1. SECURITY CLEARANCE




27. PROMOTION

CONSIDERATION CODE




  1. DATE OF RANK




  1. RYE DATE




30. ETS (Enlisted)


31. MANDATORY REMOVAL DATE

(Officers)


32. UIC


33. HIV TEST DATE

34. PANOGRAPHIC DENTAL X-RAY ON FILE



 YES  NO



35. Preceding Duty: List all AD, TTAD, AT, ADT, IADT, ADSW, FTNGD, FTNGDSW, FTNGD-CD performed in the current and previous fiscal years showing inclusive dates, number of days, location of duty and what duty was performed. If more space is needed attach additional sheet.

a. PERIOD OF PRECEDING DUTY

b. TYPE TRAINING/ DUTY (AD, ADSW, FTNGDSW, etc.)

  1. LOCATION/

INSTALLATION

  1. DUTY

PERFORMED

FROM

TO

NO. DAYS







































































































































































































NAME AND SIGNATURE OF UNIT COMMANDER



DATE


GRADE


TITLE


NAME AND SIGNATURE OF RECORDS CUSTODIAN


DATE


GRADE


TITLE


NAME, SIGNATURE AND TELEPHONE OF NGB/STATE/TERRITORY ADSW/FTNGDSW APPROVING AUTHORITY VERIFYING ALL INFORMATION.

(Approving official initial appropriate box)
 THIS TOUR APPLICATION IS APPROVED
 THIS TOUR APPLICATION IS NOT

APPROVED


DATE



GRADE



NAME AND OFFICE OF POC


COMMERCIAL AND DSN TELEPHONE


ARNG Form 1058-R, JUL 02

CHECKLIST FOR DETERMINING THE APPROVAL AUTHORITY FOR ACTIVE DUTY (AD) OR FULL-TIME NATIONAL GUARD DUTY (FTNGD) SPECIAL WORK LONG AND SHORT TOURS OTHER THAN ACTIVE GUARD RESERVE


For the purpose of these questions the terms Active Duty "AD" and Full-Time National Guard Duty "FTNGD" programs refer to ALL short and long tour paid duty programs available to soldiers within the ARNG (i.e. AT, ADT, ADSW, TTAD, FTNGD-CD, FTNGDSW, including AT with unit or service in another components, etc..) other than IDT and RMAs (Tour guidance for ADSW (T-10) is within AR 135-200; FTNGDSW (T-32) is within NGR 37-111, Office of primary responsibility is NGB-ARO-O and NGB-ARH-S respectively).


1. Under what Title and what Program (Title 10 USC/ ADSW or 32 USC/FTNGD) is this tour? _______/_______
2. Will the soldier achieve or does he/she currently have 17 years of AFS prior to / during this tour?

( __No / __Yes — Requires CNGB approval )
3. Will this soldier achieve or does this soldier have 18 years of AFS prior to / during this tour?

( __No / __Yes – Requires CNGB approval )
4. The proposed tour is for how many days? ____________ days.
5. Has the soldier performed any other AD or FTNGD (to include service in other components) within this FY?

( __No / __Yes - How Many Total Days of AD/FTNGD ____________ )
6. If this tour’s cumulative total, in conjunction with all other AD/FTNGD tours, IS LESS THAN 180 days of service this FY, then TAG has approval authority. ( TAG has authority? __Yes / __No )
7. If this tour’s cumulative total, in conjunction with all other AD/FTNGD tours, IS MORE THAN 180 days of service this FY, then CNGB must approve prior to the state publishing orders. ( CNGB must approve? __Yes / _No )

NOTE: Soldiers are not permitted to accumulate six or more years of continuous AFS and become eligible for separation pay (includes all breaks less than 31 days). Breaks in AD/FTNGD programs of less than 31 days do not constitute a valid break in service. A valid break in service is a break of 31 days or more.

8. Does the soldier have four (4) or more years of continuous AFS? ( _Yes – CNGB must approve waiver/ _ No )
9. Does the soldier's tour begin within the first 60 days of the new FY? ( __Yes / __No )
10. If the soldier's tour begins within the FIRST 60 days of the new FY, has the soldier performed MORE THAN 30 days of cumulative AD/FTNGD within the fourth quarter of the preceding FY?

( __Yes ( 60-day break waiver from CNGB is required) / __No )


  1. Will the soldier be within six months of MRD or ETS at the BEGINNING of the tour?

( __No / __Yes-Requires CNGB Exception to Policy )

12. The Application(1058) is:


a. For FTNGDSW - Do you possess a copy of the ARNG Format 1058-R which has the signature of the applicant in block 24 for the current tour? ( __Yes- then process / __No-then return for signature)

Note: When extending a tour, a new DA Form 1058-R is required for that extension period.

b. For ADSW. Do you possess a copy of the DA Form 1058-R which has the signature of the applicant in block 24 for the current tour? ( __Yes- then process / __No- then return for signature)

Note: When extending a tour, a new DA Form 1058-R is required for that extension period.


13. Publishing Orders:

a. For TAG approved tours, retain a copy of this checklist and a copy of the ARNG Format 1058-R and maintain with your file copy of the soldier's tour order.


b. For CNGB level waivers, forward this checklist (to arrive at NGB 45 days prior to desired start date), a copy of the ARNG Format 1058-R, the request for waiver and supporting documents. If approved these documents will be returned and must be maintained with your file copy of the soldier's tour order. If the waiver request is not approved, these documents will be returned with no further filing requirement.
ARNG Format 1058-1R, JUL 02


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