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PLANNED ACADEMIC PROGRAM WORKSHEET
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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 PRIVACY ACT STATEMENT OF 1974
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1. AUTHORITY: Title 10, US Code 2101 and 2104
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2. PRINCIPAL PURPOSE(S): To provide information and data necessary for administering the Army Senior ROTC program, processing, and managing of selected students for commissioning in the Army IAW
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established public law and Army Regulations.
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3. ROUTINE USE(S): To provide a prjected academic plan to determine if the applicant meets the public law requirements of two remaining academic years.
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4. VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION: Voluntary information is necessary to determine eligibility of the individual for acceptance,
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continuance, or discontinuance in the Army ROTC program.
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1. NAME OF STUDENT (LAST, FIRST, MI) 2. ACADEMIC MAJOR 3. AS OF DATE (MM/DD/YYYY) (Date of form preparation)
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4. INSTITUTION OF ATTENDANCE AND IDENTIFICATION 5. CREDIT HOURS 6. GRADE POINT AVERAGE (GPA)
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a. Name: a. Total required for degree: Term: Term:
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b. Identification (Check one):Host (1) ROTC Hours that do not count:0Curr GPA:CUM:Curr GPA:CUM:
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Extension Center (2) Total Hours Rqd for NAPS:0 Term: Term:
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Cross-Enrolled Normal Academic Progression0.00Curr GPA:CUM:Curr GPA:CUM:
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c. If attendance is at an extension center or cross-enrolled school, b. Transfer Credits accepted: Term: Term:
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list the name of the Host Institution: c. Credits toward degree Comp to date:Curr GPA:CUM:Curr GPA:CUM:
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d. Reamining for Degree:0 Term: Term:
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e. Number of authorized semesters:#DIV/0!Curr GPA:CUM:Curr GPA:CUM:
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Term: Term:
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Curr GPA:CUM:Curr GPA:CUM:
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7.TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES.
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a.b.c.
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Term:Year:Term:Year:Term:Year:
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No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.
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Total Term Hours:@0Total Term Hours:00Total Term Hours:00
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d.e.f.
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Term:Year:Term:Year:Term:Year:
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No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.
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Total Term Hours:00Total Term Hours:00Total Term Hours:00
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8. STUDENT INITIALS & DATE:TERM 1:TERM 4:TERM 7:
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(Have the student initial and date beside eachTERM 2:TERM 5:TERM 8:
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term to indicate they have been counseled)TERM 3:TERM 6:TERM 9:
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CC Form 104-R, DEC 03Page 1 of 3
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PLANNED ACADEMIC PROGRAM WORKSHEET
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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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7.TERM, YEAR, COURSE NUMBER, COURSE TITLE, COURSE CREDIT HOURS, CREDITS THAT COUNT TOWARDS ACADEMIC DEGREE, AND ACHIEVED GRADES. (CONTINUED)
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g.h.i.
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Term:Year:Term:Year:Term:Year:
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No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.
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Total Term Hours:00Total Term Hours:00Total Term Hours:00
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j.k.l.
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Term:Year:Term:Year:Term:Year:
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No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.
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Total Term Hours:00Total Term Hours:00Total Term Hours:00
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m.n.o.
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Term:Year:Term:Year:Term:Year:
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No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.No.Course TitleHrs.Cts.Grd.
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Total Term Hours:00Total Term Hours:00Total Term Hours:00
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9. REVIEW: All of the above courses are required (as minimum) for the completion of the degree: Yes No (if no, list exceptions on reverside of this form). Completion should
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result in a degree, during (YYMM):
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10. SIGNATURE OF STUDENT: 11. DATE: (MM/DD/YYYY)
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CC 104-R