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CADET ENROLLMENT RECORD
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For use of this form, see CC Pam 145-4, the proponent agency is ATCC-PA-C
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DATA REQUIRED BY THE PRIVACY ACT OF 1974
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Authority10 USC 2101, 2103, 2104, 2107, 2111, and 5 USC 301
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Principal Purpose(s)To obtain personnel data in order to determine eligibility for enrollment and serve as a source document for cadet's service record throughout participation in the ROTC Program. Provides data for the
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administration of the ROTC student commencing with application for enrollment into the ROTC Program.
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Routine UsesTo verify eligibility to participate in the ROTC Program; to provide information on addresses and telephone numbers for use in the event of death, injury, illness or unauthorized absence while
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participating in ROTC activities; to facilitate contact with complete information with a cadet during other than normal training periods; to make a matter of record the information provided by the cadet.
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DisclosureDisclosure is voluntary. However, failure to provide complete information and provide responses will suspend the enrollment process into the ROTC Program.
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PART I - GENERAL INFORMATION
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1. NAME 2. SSN 3. COLLEGE ID # 4. EMAIL
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5. LOCAL ADDRESS 5a. CITY5b. STATE5c. ZIP CODE 6. PHONE NUM
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7. PERMANENT ADDRESS 7a. CITY7b. STATE7c. ZIP CODE8. PH NUM
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9. DOB 10. POB 11. RELIGIOUS PREF 12. BLOOD TYPE 13. ACT 14. SAT
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15. SEX 16. HEIGHT 17. WEIGHT 18. MARITAL STATUS 19. DEPENDENTS 19a. NUMBER OF DEPENDENTS
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20. RACE/ETHNICITY (Check One) African American American Indian Asian Caucasian Hispanic Other
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21. CITIZENSHIP (Check One)U.S. Citizen: U.S. Born Naturalized Born Overseas With U.S. Parents Dual Citizenship (See CC PAM 145-4, 2-39)
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Non U.S. Citizen: Immigrant Alien Nonimmigrant AlienRefugee
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22. Do you have any condition that could interfere with you participating in a normal college physical education course? 22a. If "yes" explain
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23. Have you ever received Medical Disability payments from any source? 23a. If "yes" explain
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24. NEXT OF KIN 24a. ADDRESS24b. PHONE NO
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PART II - ACADEMIC INFORMATION
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25. ROTC HOST SCHOOL25a. FICE CODE26. SCHOOL OF ATTENDANCE26a. FICE CODE
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27. RESIDENCY STATUS28. ACADEMIC CLASS29. PROJECTED GRADUATION DATE30. ACADEMIC MAJOR
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31. ACADEMIC MINOR32. CREDITS TOWARD DEGREE33. CREDITS REQUIRED FOR DEGREE34. CGPA (COLLEGE)
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35. OTHER COLLEGES ATTENDED35a. YEAR(S) ATTENDED36. HIGH SCHOOL ATTENDED
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36a. GRADUATION DATE37. ROTC SCHOLARSHIP RECIPIENT37a. If "yes" what type?
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38. OTHER SCHOLARSHIPS39. JROTC EXPERIENCE
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PART III - CURRENT OR PRIOR MILITARY SERVICE (TO INCLUDE OFFICER PRODUCING PROGRAMS)
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NOT APPLICABLE (Go to PART IV)40. CURRENT SERVICE:Are you currently in the Armed Forces?40a. If "yes" which Branch?
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40b. SMP UNIT40c. Is your spouse currently a member of the Armed Forces?
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41. PRIOR SERVICE:Have you ever been enrolled in an officer producing program?41a. Were you ever disenrolled from the ROTC Program?
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41b. Were you ever enrolled in a Service Academy?41c. Were you ever discharged from the Armed Forces?41d. If "yes" what type of discharge?41e. If "yes" what was the RE Code?
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41f. Months of Active Service41g. Have you ever been discharged for medical reasons?41 h. If "yes", explain:
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CC Form 139-R-E, DEC 04REPLACES ALL PREVIOUS EDITIONS, WHICH ARE OBSOLETE. Page 1 of 6
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