Navy Option/marine Option Nrotc Program Application Form Page 3
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17College Program Application
PRINT or TYPE. Fill in all blanks. Print "None" or put "X"
in nonapplicable blanks. Continue on separate sheet if
necessary; please identify items being continued
.
PRIVACY ACT STATEMENT: Under the authority of 5 USC, 301, the information regarding your former military experience and training,
educational background, and present personal data is requested in order to validate your basic qualifications and your suitability for selection in
comparison with other applicants for the Navy-Marine Corps ROTC College Program. Your social security number will be used for purposes of
individual identification. The information will be retained by CNET, (Code OTE/083), and the NROTC Unit and will not be divulged without your
written authorization to anyone other than Navy and Marine Corps personnel involved with the administration of the program. You are not required
to provide this information; however, failure to do so will result in an inability to fairly evaluate your application and may result in an inability to
process the application.
1. NAME (Last, First Middle)
2. STUDENT ID
3. TELEPHONE NO.
4. EMAIL ADDRESS
7. PLACE OF BIRTH (City/State)
5.CURRENT MAILING ADDRESS (Number, Street, City, State, Zip)
6. DATE OF BIRTH (MM/DD/YY)
8. US CITIZEN
9. IF NATURALIZED, GIVE DATE, PLACE OF COURT
JURISDICTION, CERTIFICATION NUMBER
YES
NO
10. NAME AND ADDRESS OF PARENT OR GUARDIAN
11. COLOR BLIND (YES___/NO___)
Refraction: Cyl
Sph
Total
Left
_____
_____
______
Right _____
_____
______
VISION CORRECTABLE TO 20/20
YES
NO
12. MILITARY TRAINING AND EXPERIENCE (Past and Present, if any)
SERVICE
DATES OF DUTY
HIGHEST RANK HELD
EAOS
TYPE DISCHARGE
JROTC
POSITION(S) HELD
AWARDS
9
10
11
12
Civil Air Partol
POSITION(S) HELD
AWARDS
9
10
11
12
MITCHELL
EARHART
Other (NDCC, etc)
9
10
11
12
13. EXTRACURRICULAR ACTIVITIES
READ CAREFULLY. Identify only those activities in which you were engaged during school grades 9-12. NROTC is particularly interested in
identifying activities which an applicant has participated which involve responsibility and leadership.
ELECTED/APPOINTED
AVERAGE NO.
OFFICES HELD
EXACT POSITION(S) HELD
HOURS DEVOTED
PER WEEK
9
10
11
12
9
10
11
12
9
10
11
12
9
10
11
12
9
10
11
12
14. ATHLETIC ACTIVITIES
READ CAREFULLY. Identify only those sports which you participated in during school grades 9-12. Circle the school year in which you received
letter awards for each sport. Then circle each school year you were on varsity squads. Do not list junior varsity or “B” teams as varsity letter awards.
Do not list intramural activities.
SPECIAL RECOGNITION
LETTER
SCHOOL YEAR A
POSITION OR SPECIALTY
SPORT
(Captain, individual or state record, selected to All-City,
AWARD
TEAM MEMBER
(in which letter was earned)
County, District, Conference, State or National Team)
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
ACTIVITIES OTHER THAN THOSE ABOVE (List only if they involve considerable responsibility and leadership. Show position(s) held and
average number of hours devoted per week to activity. Attach additional sheet if needed.
CNET 1533/21 (Rev. 6-00)
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