Form 104-R - Planned Academic Program Worksheet Page 3

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PLANNED ACADEMIC PROGRAM WORKSHEET
(ROTC Cadet Comd Pam 145-4)
DATA REQUIRED BY PRIVACY ACT STATEMENT OF 1974
1. AUTHORITY: Title 10, US Code 2101 and 2104
2. PRINCIPAL PURPOSE(S): To provide information and data necessary for administering the Army Senior ROTC program and processing and managing of selected students for commissioning
in the Army IAW established public law and Army Regulations.
3. ROUTINE USES: To provide a projected academic plan to determine if the applicant meets the public law requirements of two remaining academic years.
4. VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is necessary to determine eligibility of the individual for
acceptance, continuance or discontinuance in the Army ROTC program.
1. NAME OF STUDENT (LAST, FIRST, MI)
2. ACADEMIC MAJOR
3. AS OF DATE (DAY,MONTH,YEAR)
8. INSTITUTION OF ATTENDANCE AND IDENTIFICATION
9. CREDIT HOURS
10. GRADE POINT AVERAGE (GPA)
a. Name:
a. Total required for degree:
b. Identification (Check one):
Host
(1) Total ROTC Hours:
a. Cumulative
Extension Center
(2) ROTC Hours that count:
b. Last Term
Cross-Enrolled
(3) Total Hours Rqd w/ROTC:
c. Grading Scale
c. If attendance is at an extension center or cross-enrolled school,
b. Transfer Credits accepted
name of the host institution:
c. Credits toward deg Comp to date:
d. ROTC Comp to Date (don't count towd deg):
h. Total Programmed hours (w/ROTC):
e. Remaining for Degree:
f. Remaining Terms:
g. "Adequate" Progression: e divided by f
We, the undersigned, hereby declare that the program outlined on the worksheet (on the reverse side of this statement) that
Cadet:
is about to undertake is a formally structured program approved by
(Cadet Name)
(Name of University or College)
designed to meet the requirements of a
; that the degree to be attained is the culmination of an
(TYPE OF DEGREE)
undergraduate college program of at least four years; and that the remaining credit hours shown on the worksheet
are necessary either to fulfill discipline requirements or to fulfill credit hour requirements, or both, for the attainment of the degree.
(Date)
(CADET SIGNATURE)
(Date)
(PROFESSOR OF MILITARY SCIENCE SIGNATURE)
ROTC CADET COMD FORM 104-R (Aug 98)
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