Encl. (4) to COMDTINST 1001.1A
TATTOO SCREENING FORM, CG-6052 (1-05)
Privacy Act Statement
AUTHORITY: Collection of this information is authorized per 10 USC, sections 503,505,12102, and Executive Order 9397.
PRINCIPAL PURPOSE: Information collected will be used to assist in the qualification process.
ROUTINE USES: Blanket routine use of disclosures as described in CI M1020.6 (series) and CI 1000.1A.
DISCLOSURE: Voluntary, however, failure to provide the information may delay the enlistment process or initiate action for discharge.
APPLICANT/MEMBER NAME:
SSN:
Mark all tattoos, brands, body piercings, intentional scarrings, or mutilations on the above diagram with
a number and describe below.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
UNIT:
SIGNATURE:
DATE:
APPROVED:
DISAPPROVED:
1
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