Cc Form 167-R - U. S. Army Rotc Scholarship Acceptance/declination Statement And Pms Validation

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U. S. ARMY ROTC SCHOLARSHIP ACCEPTANCE/DECLINATION STATEMENT AND PMS VALIDATION
For use of this form, see CC Reg 145-1, the proponent agency is ATCC-OP-I-S
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Authority
10 USC 2101 and 2107.
Principal Purpose(s)
To notify ROTC Cadet Command that winner accepts or declines a scholarship offer. Notifies which institution winner
will attend and reason if scholarship offer is declined.
Routine Uses
To maintain count of acceptances/declinations to enable ROTC Cadet Command to make awards to alternates. Information on
the institution is obtained to identify enrollment and allocation of funds to pay costs. Information is also used to mail medical
forms to be included in the cadet personnel file. Information on why recipient declines is maintained for statistical studies of
enrollment trends. Information is used by ROTC Cadet Command and to provide specific data to ROTC Regions and PMS.
Disclosure
Mandatory or voluntary disclosure and effect on individual not providing information - all data is mandatory. Individuals
who do not notify ROTC Cadet Command of acceptance will lose their scholarship.
1. NAME OF INSTITUTION
2. SCHOOL CODE (FICE CODE)
3. NAME OF WINNER
4. SOCIAL SECURITY NUMBER
(Last Name, First Name, MI)
(Last 4 digits)
5. SCHOLARSHIP TYPE
(check one)
PMS VALIDATION OF 3- AND 2-YEAR ADVANCE DESIGNEES
(TRANSCRIPT MUST BE INCLUDED FOR VALIDATION)
2-Year Campus Based
2-Year Graduate Program
1. GPA, Academic
2. GPA, ROTC
Cumulative
Cumulative
2-Year GRFD-ARNG
No more than 4.0 will be entered. If other than a 4-point
2-Year Dedicated ARNG
scale, convert using the table in CC Reg 145-1.
2-Year GRFD-USAR
3. MAJOR SUBJECT:
2-Year Leader's Training Course (LTC)
ACADEMIC MAJOR CODE :
2-Year Military Junior College (MJC)
4. STATUS OF MEDICAL QUALIFICATION:
2-Year Green to Gold
Qualified
2-Year Graduate Green to Gold
Has Changed (Physical submitted to DoDMERB)
2-1/2 - Year GRFD-ARNG
5. PMS RECOMMENDATION:
3-Year (or 2-1/2-Year) Campus Based
Recommended
3-Year GRFD-ARNG
Not Recommended
3-Year Green to Gold
6. PROJECTED GRADUATION DATE (YYYYMM):
3-Year Advance Designee (AD)
4-Year (or 3-1/2-Year) Campus Based
7. SCHOLARSHIP AWARD DATE(YYYYMMDD):
4-Year Green to Gold
4-Year High School
6. DECISION:
ACCEPT
DECLINE
8. PMS REMARKS:
7. REASON FOR DECLINATION:
1 - Commitment
2 - Academic Major Restriction
3 - Non-Military Scholarship
4 - Other Military Scholarship
SIGNATURE OF PMS
DATE (YYMMDD)
5 - ROTC Too Time Consuming
6 - No Longer Interested
7 - Other
(Please explain)
I, the undersigned, hereby acknowledge receipt of notification of my selection for the award of an Army ROTC Scholarship. In accepting this
scholarship I understand that I will obtain a degree in the academic major indicated on my application/contract or I may lose my scholarship if I
change to another academic discipline without prior written consent of the Professor of Military Science.
8. SIGNATURE
9. DATE
CC FORM 167-R, OCT 2005
PREVIOUS EDITIONS ARE OBSOLETE

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