Form 173-R - U.s. Army Rotc Green To Gold 4-, 3-, And 2-Year Scholarship Application

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U.S. ARMY ROTC GREEN TO GOLD 4-, 3-, AND 2-YEAR SCHOLARSHIP APPLICATION
For use of this form, see CC Reg 145-1, the proponent agency is ATCC-OP-I-S
DATA REQUIRED BY THE PRIVACTY ACT OF 1974
Authority
10 USC 2102 and 2107.
Principal Purpose Form is used to make application for a Green to Gold 4-, 3-, or 2-year scholarship.
Routine Uses
Form is used to obtain selection and eligibility information on applicants for 4-, 3-, or 2-year scholarships.
Disclosure
Information provided on this form is mandatory, without the data provided on this form, the application cannot be considered for a scholarship.
1. SSN
2a. LAST NAME
2b. FIRST NAME
2c. MI
3. DATE OF BIRTH (Enter as YYMMDD)
4. SEX (M-Male, F-Female)
5. RACE/ETHNIC CODE
6a. HOME ADDRESS: STREET
6b. CITY
6c. STATE
6d. ZIP CODE
7a. WORK ADDRESS: STREET (Unit of Assignment)
7b. CITY
7c. STATE
7d. ZIP CODE
8a. TELEPHONE NUMBER: HOME
9. MARITAL
11. SPOUSE MILITARY
12a. SOURCE OF
13. RANK
(Include Area Code/Include Country Code for overseas)
STATUS
(Y-Yes, N-No)
CITIZENSHIP
8b. TELEPHONE NUMBER: WORK
10. NUMBER OF DEPENDENTS
12b. NATURALIZATION NUMBER
14a. DATE OF ENLISTMENT
14b. ENLISTED EXPIRATION
15. MOS
16. GENERAL TECH
17.
APFT
2-MILE RUN
APFT
APFT
(Enter as YYMMDD)
DATE (Enter as YYMMDD)
(GT) SCORE
PUSH UPS SIT UPS
MIN SEC
SUM
PASS
14c. IF DATE SPECIFIED IS A REENLISTMENT DATE, INDICATE
PERIOD OF ORIGINAL ENLISTMENT (Enter as YYMMDD)
18. CIVIL CONVICTIONS
19a. FAVORABLE SECURITY
19b. WHAT TYPE
CLEARANCE COMPLETED
20. NAME OF COLLEGE OR UNIVERSITY YOU WILL BE
21. SCHOOL CODE
24. RESIDENT
25. ACADEMIC MAJOR
ATTENDING
STUDENT STATUS
CODE
22. IF ITEM 20 DOES NOT HOST ARMY ROTC, INDICATE
23. SCHOOL CODE
26. SCHOLARSHIP TYPE
27.
Are you interested in the Green to Gold Active Duty
THE SCHOOL WHERE YOU WILL TAKE ROTC
(Masters=M, 2-Yr=2, 3-Yr=3, 4-Yr=4)
Option Program to obtain your commission (2-Yr only)?
YES
NO
28. LIST AWARDS, DECORATIONS OR SPECIAL RECOGNITION BESTOWED UPON APPLICANT WHILE ON ACTIVE DUTY
29. EMAIL ADDRESS OF APPLICANT
30. FAX NUMBER OF APPLICANT
31. SIGNATURE OF APPLICANT
DATE
32. VERIFICATION AND SIGNATURE BY THE MILPO OFFICE (INCLUDE RANK)
DATE
CC FORM 173-R, NOV 03
REPLACES ROTC CADET COMMAND FORM 173-R, DTD AUG 01
Page 1 of 2

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