Navy Option/marine Option Nrotc Program Application Form (Page 4 of 17) in pdf

15. DUTY OR EMPLOYMENT

List in chronological order beginning with the present, each period of employment, self-employment, part-time employment, and/or unemployment.

List inclusive dates for each period. If discharged for cause from any employment, so state.

A. DATES

B. NAME OF EMPLOYER

C. ADDRESS

D. TYPE WORK PERFORMED

FROM

Present

16. EDUCATION

List in chronological order, beginning with last school attended. Include any/all college work. Attach transcripts.

A. DATES

B. NAME OF SCHOOL

C. ADDRESS

D. MAJOR

E. DEGREE

FROM

17. COLLEGE BOARD SCORES

18. HIGH SCHOOL RECORDS

19. ANTICIPATED DATE OF NROTC

ENROLLMENT

PSAT

Verbal

Math

Class Rank

ACADEMIC MAJOR

SAT

Verbal

Math

Class Size

ACT

Verbal

Math

GPA

on a scale of

YES

20. Have you ever been arrested or convicted of trafficking illegal drugs?

21. Have you signed an Enlistment Contract (DD Form 4) with any of the Armed Forces of the United States? (If answer is YES, list

the date, place, service and current status of enlistment.)

22. Have you ever been arrested, detained, indited, summoned into court, or convicted for any violation of civil or military law

(includes juvenile offenses and moving traffic violations)? If answer is YES, give complete description of incident, name and place

of court, nature of offense, date and disposition of case.

23. Are you currently awaiting trial or sentence, on probation, under suspended sentence or under any type of military or civilian

restraint as a result of violation of law or regulation?

24. Have you ever been known by any other name or names other than that used in this application? (If answer is YES, even if such

differences were only differences in spelling, explain in affidavit form and submit with application.)

25. Do you have any moral obligations or personal convictions that will prevent you from conscientiously bearing arms and

supporting and defending the Constitution of the United States against all enemies, foreign and domestic?

26. Have you ever taken any narcotic, sedative, or tranquilizer drugs other that as prescribed by a physician or dentist? (If answer is

YES, set forth on an attached sheet full circumstances, including approximate times, amounts taken, period over which taken and

intent for further use.)

27. Have you ever made application for or signed any agreement concerning any program leading to a commission in any of the

Armed Forces of the United States? (If answer is YES, list the date, place of application, program applied for and current status.)

28. Have you ever used LSD, marijuana, sniffed glue or used any other hallucinogen, hypnotic, stimulants, or other know harmful or

habit-forming drugs and/or chemicals? (If answer is YES, set forth on an attached sheet full circumstances, including approximate

times, amounts taken, period over which taken and intent for further use.)

I certify that all information given by me is complete and correct to the best of my knowledge.

29. SIGNATURE

30. DATE

If you have answered YES to any of the above questions, respond as indicated on a separate, attached sheet of paper.

I understand that this applicant questionnaire does not obligate me in any way, and that I may withdraw my application at any time.

NROTC COLLEGE PROGRAM OATH

“I do solemnly swear (or affirm) that I will support and defend the constitution of the United States against all enemies, foreign and domestic: That I

will bear true faith and allegiance to the same: And that I take this obligation freely, without any mental reservation or purpose of evasion.”

STUDENT’S SIGNATURE IN FULL

CNET 1533/21 (Rev. 6-00) (Back)

Navy Option/marine Option Nrotc Program Application Form Page 4

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