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-ROI

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.

1a. ACADEMIC SCHOOL

2a. HOST SCHOOL

2b. FICE

1b. FICE

4. SOCIAL SECURITY NUMBER

3. NAME OF WINNER

(Last 4 digits)

(Last Name, First Name, MI)

PMS VALIDATION OF 3- AND 2-YEAR ADVANCE DESIGNEES

5a. SCHOLARSHIP CONTROL NUMBER

(TRANSCRIPT MUST BE INCLUDED FOR VALIDATION)

(A Scholarship offered without a Scholarship Control Number is unauthorized and not valid.)

Validation must be completed by 1 July IAW CC PAM 145-1, 2-2h(7)

b. GRFD CONTROL NUMBER (if applicable)

1. GPA, Academic

2. GPA, ROTC

Cumulative

6. SCHOLARSHIP TYPE

(check one)

Campus Based

2-Year Campus Based

No more than 4.0 will be entered. If other than a 4.0

2-Year Graduate Program

scale, convert using the table in CC Reg 145-1.

2-Year Leader's Training Course (LTC)

3. MAJOR SUBJECT:

2-Year Advanced Designee (AD)

ACADEMIC MAJOR CODE :

3-Year (or 2.5-Year) Campus Based

3-Year Advance Designee (AD)

4. STATUS OF MEDICAL QUALIFICATION:

4-Year (or 3.5-Year) Campus Based

Qualified

GRFD

2-Year GRFD-ARNG/USAR

Has Changed (Physical submitted to DoDMERB)

2-Year Ike Skelton Scholarship

5. PMS RECOMMENDATION:

2-Year Dedicated ARNG/USAR

Recommended

3-Year (or 2.5-Year) Dedicated ARNG/USAR

Green to Gold

2-Year Green to Gold

Not Recommended

2-Year Graduate Green to Gold

6. PROJECTED GRADUATION DATE (MMYYYY):

3-Year Green to Gold

4-Year Green to Gold

7. SCHOLARSHIP AWARD DATE(YYYYMMDD):

High School

4-Year High School

3-Year Advance Designee (AD)

8. PMS REMARKS:

7. DECISION:

DECLINE

8. REASON FOR DECLINATION:

1 - Commitment

2 - Academic Major Restriction

3 - Non-Military Scholarship

4 - Other Military Scholarship

5 - ROTC Too Time Consuming

6 - No Longer Interested

7 - Other

(Please explain)

PMS SIGNATURE

DATE (YYMMDD)

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.

10. DATE

9. CADET'S SIGNATURE

CC FORM 167-R, JAN 2013

PREVIOUS EDITIONS ARE OBSOLETE