afrotc det 159 application - university of central...

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Any application received inŎƻƳǇƭŜǘŜκƛƴ wrong format will be [email protected]

Review all medical information on the next page, if you have questions, please consult a doctor

Email completed application file to [email protected]

Miscellaneous Information/Common Disqualifications * This is only guidance and each waiver request will be reviewed on a case-by-case basis.

1. Depression/Anxiety requiring medications for control

* (Needs to be off of all medications (24 months for general anxiety and 36 months for

depression/comorbid anxiety) and have a Psychiatry evaluation for waiver consideration)

2. Attention Deficit Hyperactivity Disorder (ADHD) or (ADD)

* INFORMATION REQUIRED

CSB RE-LOOKS:

Must be off medication for a minimum of 12 months, pharmacy record for the last

2 years

All medical documents pertaining to ADHD

Letter from Detachment Commander addressing members involvement in

program

College transcripts

Letter from university addressing if applicant required and/or has any academic

accommodations

HSSPs:

Must be off medication for a minimum of 15 months, pharmacy record for the last

2 years

All medical documents pertaining to ADHD

Current note from last prescribing provider that indicates continued medication is

not required for acceptable educational, occupational or social function

Evidence of successful academic (2.0 GPA or greater) and work endeavors while

off medication

Evidence that applicant does not have, and/or require an Individual Education

Plan (IEP) or 504 Plan

3. Eczema/Atopic dermatitis after age 12

Eczema/Atopic dermatitis/ is disqualifying for appointment/enlistment/induction

per DoDI 6130.03

Members medically classified as having mild forms of eczema will be considered

for a waiver. If a waiver is granted certain occupational restrictions may be

applied to secure personal and mission safety.

4. Allergies to foods, peanuts, tree nuts, stinging insects: With history of anaphylaxis

Positive allergy testing

Require individual to carry a Epi-pen

5. Asthma, Exercise Induced Asthma (EIA) or Reactive Airway Disease

(RAD):

* (The following must be met for waiver consideration)

No use of controller/inhaler or rescue medication within the past 3 years.

No exacerbations requiring acute medical treatment within the past 3 years.

No use of oral steroids within the past 3 years.

* Methacholine Challenge will only be requested by AETC/SGP when a cadet’s

condition is ambiguous or there is an uncertain history. Please do not have your

cadets accomplish this test without our recommendations.

* Does not guarantee a waiver will be granted

6. Orthopedic Injuries (knees and shoulders) (1) Asymptomatic for 6 months to 1 year, depending on degree of injury

(2) Current Orthopedic consult addressing ROM, strength, stability and if cleared

for full unrestricted physical activity

7. Medications versus Diagnosis and The “Disqualifying Medication List”:

Certain medications and the reason for taking the medications can be disqualifying.

This list of disqualifiers is not all inclusive. Other conditions may render you ineligible to

serve in the US Air Force. AFROTC Cadre personnel are not doctors and cannot offer

medical advice. If you have any of the listed conditions or something else that you think

could render you ineligible to serve, consult a doctor before you submit an application to the

detachment.

DEPARTMENT OF THE AIR FORCE AIR EDUCATION AND TRAINING COMMAND

MEMORANDUM FOR NEW CADET

FROM: AFROTC DET 159 PO BOX 162380 BLDG 501, RM 103 ORLANDO FL 32816-2380

SUBJECT: Establishment of Air Force ROTC Records

1. Welcome to Air Force ROTC, Detachment 159! You’ve made a great choice! Now it’s timefor paperwork. You’ll find quite a few forms in this package. Some are rather in-depth and difficult to complete. Don’t let that intimidate you! Please take this packet home and fill out the forms as best you can. Skip over anything you are unsure of or you don’t understand. We’ll go over everything with you when you return.

2. You will also need to bring in the following documents. You will need to bring in theoriginals. We will copy them and hand the documents back to you. You must bring these documents with you when you meet with a cadre member for application completion or your application will not be considered complete.

____ Birth certificate (Original/certified copy) (English translation if in another language) ____ Naturalization Certificate (if applicable) ____ Social Security Card (Must be signed and cannot be laminated) ____ ACT/SAT Scores (Unless they are on your transcript) ____ Academic Transcript (HS or College, whichever is most recent, official/unofficial) ____ JROTC certificate of completion ____ CAP Award Certificate ____ Other (ie. Private Pilot’s License, DD Form 214, Eagle Scouts, Gold Palm, etc.)

3. If you have any questions or need to reschedule, please call 407-823-1247 or email me [email protected].

//SIGNED// DAVID T. SCHIFFERT, Lt Col, USAF Operations Flight Commander

1

Welcome to AFROTC, Detachment 159, and the University of Central Florida. This package is

designed to assist you in completing the paperwork required to join Air Force ROTC. You must

follow these instructions, or your application will be rejected. It is very important that you

complete the forms and return them as soon as possible.

While this application package seems lengthy, many of the items are for our AFROTC Instructor

use only. Do not insert text anywhere in these forms except for where there is already an

established, fillable text box in adobe.

GENERAL INSTRUCTIONS FOR COMPLETING FORMS

1. All of the sections contain instructions that should provide sufficient explanations for

completing all the required forms correctly. Please read all information carefully to preclude

mistakes. However, should you need further guidance, feel free to contact a detachment cadre

member at (407) 823-1247.

3. Include ZIP codes for every city and state address listed. If necessary, refer to a ZIP code

directory and use the main city post office ZIP.

4. It is advisable for you to have your parents read and review all forms so they are also aware of

the program and its requirements. In addition, they will probably be able to supply or verify the

information required on the forms.

5. If you are not 18 years old yet and will not reach the age of 18 by the first day of school, it

will be necessary for a parent or legal guardian to be present for part of the interview to sign

some of the forms.

6. Incorrect or incomplete forms will cause delays in your processing. Be sure to follow all

the directions exactly. DO NOT sign or initial these forms before emailing them. You will

sign the forms in person during your appointment at the detachment.

2

OK, LET’S GET STARTED:

DD FORM 2983

This form is required for all applicants. Read form in its entirety. You will sign this when you

meet with a cadre member.

AFROTC IMT 20

NAME: Application for AFROTC Membership.

PURPOSE: This form determines eligibility for membership in an Air Force Reserve Officer

Training Corps program.

SPECIFIC INSTRUCTIONS:

Name: Print your FULL NAME (last name, first name, Middle Name)

Social Security Number: LEAVE BLANK (This will be filled in once you arrive for the

interview).

Date of Birth: MM/DD/YYYY

Gender: Check the appropriate block

Ethnic Group: Check the appropriate block

Marital Status: Check the appropriate block

Place of Birth: City and State

Number of Dependents: This is either your spouse if you are married, or children regardless of

your marital status

College/University: Enter the school in which you will be attending, and your student ID

number. If you will be attending a cross-town school (not UCF), enter that school name

Projected Graduation Date: Enter the Semester and year you will be graduating from college

(Spring 2017, Fall 2017, etc)

Academic Major: Enter the major you are pursuing

Permanent Mailing Address: Enter the address where you reside when not at school, normally

your parents’ address.

3

In Case Of Emergency Contact: Please give a name.

Telephone Number of Emergency Contact

Temporary Mailing Address: Enter the address and telephone number of your address while at

school (if known).

Selective Service Number (www.sss.gov) – MALES ONLY

Background Experience: Check the appropriate block(s)

Military service of parent or guardian: If your parent or guardian has prior/current military

service, provide the requested information.

Complete the form by checking the appropriate block next to the questions

AFROTC IMT 35

NAME: Certification of Involvements with Civil, Military, or School Authorities/Law

Enforcement Officials.

PURPOSE: This form is the basic document used for evaluating the moral character of an

applicant. Good moral character is a prerequisite for initial or continued Professional Officer

Crops (POC)/College Scholarship Program (CSP) membership. Note that after you contract, a

check of national agencies will be made and all discrepancies will need to be explained.

Therefore, it is important to make certain that the information you supply is complete and as

accurate as possible.

GENERAL INSTRUCTIONS: Carefully read Section I. Ensure that you fully understand the

content and are aware of your responsibility at this time to report completely and honestly any

such incidents/involvements you have had in the past. Also know that while in the AFROTC

program you must immediately report to detachment personnel all future involvement/incidents

you may encounter, no matter how insignificant you think they may be.


Section I: Print your first name, middle initial, and last name (if not already typed)

Section II: Type of Involvement: List all involvement with authorities; this includes all law

enforcement officials, military authorities, school authorities, and federal law enforcement

agencies (no matter how insignificant or the outcome/final disposition). Describe the

involvement, i.e., speeding 65 in a 55, ran a red light, careless driving, etc. Also list any

suspensions during high school. If you have not had any of the above print NONE on the first

line is section II.

Date of Involvement: Indicate at least the month and year. Obtain exact date if possible.

http://www.sss.gov/

4

Name and Address of Arresting Authority/Court: Indicate the authority, i.e., Kansas Highway

Patrol, Lawrence Police Department, KU Police Department, etc. This is the name of the issuing

agency, NOT the name of the police officer who issued the citation.

Disposition/Finding and Sentence: Enter the amount of fine, loss of points, dismissed, found not

guilty, etc. If fined, indicate whether it was paid or not. Include a date of when the issue was

completed.

Indicate if you were detained, confined, or placed on probation for any of the involvement.

Indicate if the use of drugs or alcohol was cited for any of the involvements.

DD FORM 93

NAME: Record of Emergency Data

PURPOSE: This form provides current emergency information on each member. It serves as

an official document that is required by law for designating the beneficiaries of unpaid pay and

allowances.


Block 1-2: Provide your name and SSN, if not already typed

Block 4a-b: Provide this information for your spouse, if applicable. If you are not married, leave

both blocks blank

Check the appropriate box to indicate whether you are single, divorced, or widowed.

Block 5: Provide the requested information. Be sure to include a full address, including city,

state, and zip code. If you do not have children, type “None” in the first box within the first

column.

Block 6a-7b: Provide the requested information. Be sure to include a full address, including city,

state, and zip code. If other than natural father or mother, indicate the relationship within the

applicable box. If unknown or deceased, indicate “Unknown” or “Deceased” in the applicable

box.

Block 8a-b: If you do not want us to notify one of your parents in an emergency, indicate that by

typing either “Father” or “Mother” in box 8a. Designate a person to be notified instead of your

mother or father in box 8b.

Block 11a-d: Should you die while on active orders (ex: Field Training), you will be entitled to a

death gratuity. Indicate who this should be paid to. Percentages must add up to 100% and must

be in 10% increments.

5

Block 12a-13b: Again, should you die on active orders, who should any unpaid allowances be

paid to and who should take possession of your body (13a). Only the following persons may be

named as a Person Authorized to Direct Disposition (PADD): surviving spouse, blood relative of

legal age, or adoptive relatives of the decedent.

AFROTC IMT FORM 500

NAME: Restrictions on Personal Conduct in the Armed Forces

PURPOSE: To advise military personnel on certain restrictions on their personal conduct. This

form is for informational purposes only.

Read this form in its entirety. You will sign this when you meet with a cadre member.

DD FORM 2005

NAME: Privacy Act Statement - Health Care Records

PURPOSE: This form authorizes detachment and health care personnel to use your social

security account number (SSAN), and other voluntary information provided by you, in

conjunction with maintaining your medical records within your personnel file and for conducting

official business.


AF IMT 3010

Mark the appropriate marital status on the top of the form. Read the rest of the form and you

will sign it when you meet with a cadre member.

DEPENDENCY POLICY STATEMENT OF UNDERSTANDING


DRUG DEMAND REDUCTION MEMORANDUM OF UNDERSTANDING


AFROTC FORM 28

Read this form in its entirety. If accepted into AFROTC, you will need schedule an appointment

at the Health Center on campus or your family doctor to get this form filled out and signed and

stamped by a physician. This form must be returned to the detachment BEFORE the start of

school.

6

REQUEST FOR RELEASE OF STUDENT RECORDS

These forms allow AFROTC to obtain copies of your transcripts to be used for award packages

and commissioning.


DUAL CITIZENSHIP RENOUNCEMENT STATEMENT AND PROOF OF PASSPORT

DESTRUCTION

This form is required for dual-citizen cadet applicants only. If you are a dual citizen, read

this form in its entirety. You will fill out and sign this form in person during your interview.

This form is used during your security clearance investigation. Your signature verifies that you

understand that you may be required to renounce your dual-citizenship before you’ll be allowed

to commission. Please ask all questions before you sign this form during your application

appointment.

AF IMT 2030

NAME: USAF Drug and Alcohol Abuse Certificate

PURPOSE: The purpose of this form is to evaluate your acceptability into the Air Force and to

identify any possible drug or alcohol related problems. Also, this form is used to inform you of

the Air Force policy regarding drug and alcohol use/abuse.

GENERAL INSTRUCTIONS: Carefully read the instructions contained on the form. It is

important that this form be completed accurately and that you understand the content. You will

complete this form in person when you meet with a cadre member.

RECRUIT/TRAINEE PROHIBITED ACTIVITIES ACKNOWLEDGMENT

INSTRUCTIONSIn accordance with DoDI 1304.33, this form will be read and signed no later than the first visit with a recruiter following a recruit's entry into the Delayed Entry Program or read and signed no later than the first day of entry-level training for a trainee. As a minimum, the signed original will be retained in the recruit's file until they enter active duty or in the trainee's file until they detach from the training command or school they are attending. Please initial beside each entry acknowledging that you have read and understand the statement.1. RECRUIT/TRAINEE NAME (Last, First, Middle)

4. RECRUITING OFFICE/TRAINING COMMANDADDRESS (City, State, ZIP Code)

5. DATE SIGNED(YYYYMMDD)

2. PAY GRADE 3. RECRUITING OFFICE/TRAINING COMMAND

6. SIGNATURE

7. I ACKNOWLEDGE AND UNDERSTAND THAT AS A RECRUIT OR TRAINEE, I WILL NOT:

10. APPROVED BY

(Initial) a. Develop, attempt to develop, or conduct a personal, intimate, or sexual relationship with a recruiter or trainer.This includes, but is not limited to, dating, handholding, kissing, embracing, caressing, and engaging in sexualactivities. Prohibited personal, intimate, or sexual relationships include those relationships conducted in person orvia cards, letters, e-mails, telephone calls, instant messaging, video, photographs, social networking, or any othermeans of communication.

b. Establish a common household with a recruiter/trainer, that is, share the same living area in an apartment, house,or other dwelling.

f. Gamble with a recruiter/trainer.

h. Lend money to, borrow money from, or otherwise become indebted to a recruiter/trainer.

g. Make sexual advances toward, or seek or accept sexual advances or favors from, a recruiter/trainer.

e. Allow entry of any recruiter/trainer in my dwelling or privately-owned vehicle except to conduct official business.Exceptions are permitted for official business when the safety or welfare of the recruiter/trainer is at risk.

d. Attend social gatherings, clubs, bars, theaters or similar establishments on a personal social basis with a recruiter/trainer.

c. Consume alcohol with a recruiter/trainer on a personal social basis.

8. EXCEPTIONS. Exceptions may be granted to accommodate relationships that existed prior to the start of the recruiting process orprior to the trainee starting the formal training process. These relationships include, but are not limited to, family members. Onlythe Recruit's or Trainee's Commander, O-4 or higher, or higher level authority, has the authority to approve these exceptions.Approved exceptions will be documented below and signed by the Recruit's or Trainee's Commander, O-4 or higher, or a higher-level authority.DESCRIPTION OF EXCEPTION(S):

a. d. SIGNATURE/RANKb. TITLE c. DATE SIGNED(YYYYMMDD)

DD FORM 2983, JAN 2015 Adobe Designer 9.0

9. VIOLATIONS. Violations of any part of paragraph 7.a. through 7.h., not granted an exception in paragraph 8, mayresult in disciplinary action.

(Initial)

AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoD Instruction 1304.33, Standardized Protection Policies Prohibiting Inappropriate Relations Between Recruiters and Recruits, and Trainers and Trainees. PRINCIPAL PURPOSE(S): To document your understanding of the prohibitions identified in section 7 of this form. ROUTINE USE(S): The DoD Blanket Routine Uses found at http://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply to this collection. DISCLOSURE: Voluntary. However, if you fail to provide the requested information or complete this form, you might not be able to complete your enlistment or receive training.

PRIVACY ACT STATEMENT

Cadet AFROTC DET 159/AETC

PO Box 162380, Orlando, FL 32816-2380

Commander

THIS PAGE INTENTIONALLY LEFT BLANK

JHallett

Rectangle

ANSWER THE FOLLOWING QUESTIONS (Check the applicable blocks. If yes, explain on reverse.)

APPLICATION FOR AFROTC MEMBERSHIP OMB No. 0701-0105Expires 20070531(Please read Privacy Act Statement on reverse before completing this form.)

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searchingexisting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding thisburden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, WashingtonHeadquarters Services, Directorate for Information Operations and Reports, (0701-0105), 1215 Jefferson Davis Highway, Suite 1204, Arlington, Virginia 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with acollection of information if it does not display a current valid OMB control number. Please DO NOT RETURN your form to the above address. Returncompleted form to your AFROTC detachment.

GENERAL MILITARY COURSE/PROFESSIONAL OFFICER COURSE/COLLEGE SCHOLARSHIP PROGRAM APPLICANT DATAI.NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER DATE OF BIRTH (MM/DD/YYYY) GENDER

FEMALE MALE

ETHNIC GROUPAMERICAN INDIAN ORALASKAN NATIVE

ASIAN HAWAIIAN BLACK, NOT OFHISPANIC ORIGIN

WHITE, NOT OFHISPANIC ORIGIN

DECLINE TO RESPONDHISPANIC

MARITAL STATUS NUMBER OF DEPENDENTSPLACE OF BIRTH (City/State) MARRIED SINGLE DIVORCED

COLLEGE/UNIVERSITY STUDENT ID PROJECTED GRAD MONTH & YEAR ACADEMIC MAJOR

PERMANENT MAILING ADDRESS (Street, City, State, ZIP Code, andTelephone Number and E-mail Address)

IN CASE OF EMERGENCY CONTACT

TELEPHONE NUMBER EMERGENCY CONTACT (Include Area Code)

BACKGROUND EXPERIENCE

CURRENT MAILING ADDRESS (Dorm, Room, Telephone Number, Street, City, JUNIOR ROTC CIVIL AIR PATROL AWARDSEAGLE SCOUTState, and ZIP Code)

NONE 3-YEAR YESYES NO

NO1-YEAR 4-YEAR MITCHELL

2-YEAR EARHARTSELECTIVE SERVICE NUMBER (Males Only)

SPAATZBRANCH OF SERVICE:

MILITARY SERVICE OF PARENT OR GUARDIAN CURRENT STATUS OF PARENT OR GUARDIANYEARS OF SERVICE HIGHEST GRADEAIR FORCE

ARMYMARINESNAVY

COAST GUARDMERCHANT MARINE

iiRETIREDMILITARY

ACTIVEDUTY

YES NOAre you now or have you ever been an enlisted or warrant officer of any component of the US armed forces (i.e., Reserve, USN, USAF,USMC, USA, USCG, Merchant Marine)? If yes, complete the rest of this block.

BRANCH OF SERVICE FROM (Mo/Yr) TO (Mo/Yr) TYPE OF DISCHARGE YEARS REMAINING ONENLISTMENT

HIGHEST GRADE

YES NO1. Have you ever applied for, been enrolled, or on contract in an Officer Training Program of the US Army, USAF, USMC, USCG, USN, MerchantMarine, or preparatory schools? (If yes, indicate in remarks where and when.)

2. Are you now, or have you ever been, a commissioned officer of any component of the armed forces (including Reserve, USAF, USN, USA,USMC, USCG, Merchant Marine)?

3. Are you now, or have you ever been, an officer of the Health Services and Mental Health Administration?

4. Are you now, or have you ever been, a member of the National Oceanic Atmospheric Administration?

5. Are you a U.S. Citizen? If yes, how obtained: BIRTH NATURALIZED

6. Have you ever taken the AFOQT? (If yes, indicate in remarks section where and when.)

7. Have you ever had a physical for entry into the armed forces, Air Force ROTC, etc.? (If yes, indicate in remarks section where and when.)

8. Have you ever been denied enlistment into the armed forces?

9. Do you already have a degree (BA, BS, etc.)?

10. Are you an AFROTC Scholarship Designee? NO YES (Check one) 4-year 3-year

11. Are you a conscientious objector? (A conscientious objector is defined as: one who has or had a firm, fixed and sincere objection toparticipation in war in any form or to bearing of arms because of religious training or belief, which includes solely moral or ethical beliefs.)

12. Are you now or have you ever been affiliated with any organization or movement that seeks to alter our form of government byunconstitutional means, or sympathetically associated with any such organization, movement, or members thereof? (If yes, please describe.)

AFROTC FORM 20, 20060901, V1 PREVIOUS EDITIONS ARE OBSOLETE.

(If a naturalized citizen, or born outside of the U.S. of American parents, submit proof of citizenship. Reference AFROTCI 36-2011.)

Dual-Citizen Country:(if applicable)

JHallett

Typewritten Text

CIVILIAN

JHallett

Sticky Note

Unmarked set by JHallett

JHallett

Sticky Note

None set by JHallett

YES NOANSWER THE FOLLOWING QUESTIONS (CONT)13. Do you understand that participation in Air Force ROTC requires strenuous physical activity? (You will be required to obtain medicalclearance from a physician prior to program entry.)II. STATEMENT OF UNDERSTANDING

I understand that membership in the General Military Course (GMC) or attendance at Field Training (FT) does not guarantee that I will be accepted into theProfessional Officer Course (POC). I understand that if I am not on scholarship, attendance at FT does not guarantee or commit me to enter the POC.GMC scholarship cadets who attend the first AS 200 class or Leadership Laboratory incur an Active Duty Service Commitment and are liable to call toextended active duty or recoupment (which includes payback of scholarship benefits received during the AS 100 year).

SIGNATURE OF APPLICANT DATE

III. OATH OF ALLEGIANCE

swear or affirmI do solemnly that I will support and defend the Constitution of the United States against all enemies foreign or domestic; that I willbear true faith and allegiance to the same; and that I take this obligation freely, without any mental reservation or purpose of evasion.

SIGNATURE OF APPLICANT DATE

REMARKS

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 33, Appointment in Regular Component; 10 U.S.C. 103, Senior Reserve Officers’ Training Corps as implemented by AFROTCI 36-2011,Air Force Reserve Officers’ Training Corps; and E.O. 9397 (SSN). PURPOSE: To process and manage selected students for acceptance into the USAF ROTC program. ROUTINE USES: This information may be disclosed to federal, state, local or foreign law enforcement authorities for investigating or prosecuting aviolation or potential violation of law; to federal, state, or local agencies to obtain information concerning hiring or retention of an employee, issuance of a securityclearance, letting of a contract, or issuance of a license, grant or other benefit; to a federal agency in response to its request in connection with the hiring orretention of an employee, issuance of a security clearance, reporting of an investigation of an employee, letting of a contract, issuance of a license, grant, orother benefit by the requesting agency to the extent that the information is relevant and necessary to the requesting agency's decision on the matter; to acongressional office in response to their inquiry made at the request of the individual; to the Office of Management and Budget in connection with review ofprivate relief legislation as set forth in OMB Circular A-19; to foreign law enforcement, security, investigatory, or administrative authorities to comply withrequirements of international agreements and arrangements; to state and local taxing authorities in accordance with Treasury Fiscal Requirements ManualBulletin 7607; to the Office of Personnel Management (OPM) concerning information on pay and leave, benefits, retirement deductions, and other informationnecessary for OPM to carry out its functions; to NARA for records management functions; and to the Department of Justice for pending or potential litigation. DISCLOSURE: Furnishing the information is voluntary. Failure to provide requested information will hinder processing.

AFROTC FORM 20, 20060901, V1 (REVERSE)

FOR OFFICIAL USE ONLY (When filled in)

CERTIFICATION OF INVOLVEMENTS WITH CIVIL, MILITARY OR SCHOOLAUTHORITIES/LAW ENFORCEMENT OFFICIALS

I. STATEMENT TO THE APPLICANT/CADETA. The Detachment Commander must know if you have ever been arrested, convicted, involved with law enforcement officials or authorities for him/her to

determine if you meet the character requirements for membership in Air Force ROTC. It is necessary for you to report any involvement with civil, military, or school authorities/law enforcement officials regardless of its insignificance , disposition, or finding on the certification provided below. Include traffic violations and any incidents which resulted in your being judged a juvenile offender. A finding of not guilty or advice by an attorney, court official, or

anyone else to consider your record as clear does not constitute authority to leave the involvement off of the certification.

B. In the future, you must report any civil involvements to the Detachment Commander or his/her designated representatives within 72 hoursoccurrence. If such incidents occur during a period of leave from the institution (e.g., student teaching or foreign study), attendance at Field Training, or during normal vacation periods, the 72-hour time limit will apply effective with the official date of your return to the institution.

C. Concealing or failing to report an involvement with civil, military, or school authorities/law enforcement officials, giving false information or claimingsubsequent to initial certification that you were unaware of the contents of this document may result in elimination from consideration for membershipin the Air Force ROTC program; or, if already a member, may result in your discontinuance from the Air Force ROTC program. The information reportedon this certification form will be treated as confidential matter, subject to the provisions of the Privacy Act of 1974 and the Freedom of Information Act.

CERTIFICATE

CERTIFY THAT THE INFORMATION CONTAINED IN THE FOLLOWING CERTI-I,FICATIONS INCLUDES ALL ARRESTS, DETENTIONS, CONVICTIONS, INVOLVEMENTS, ETC., THAT I HAVE HAD WITH CIVIL, MILITARY (INCLUDINGART. 15S), OR SCHOOL AUTHORITIES/LAW ENFORCEMENT OFFICIALS REGARDLESS OF DISPOSITION OR SEEMING INSIGNIFICANCE. THE LISTS

ARE COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

II. CERTIFICATION I

TYPE OF INVOLVEMENT / ORIGINALCITATION

DATE OFINVOLVEMENT

NAME AND ADDRESS OF ARRESTINGAUTHORITY/COURT

DISPOSITION/FINDINGAND SENTENCE

WERE YOU DETAINED, CONFINED,OR PLACED ON PROBATION FORANY OF THE ABOVE?

WAS THE USE OF DRUGS ORALCOHOL CITED? NO ACTION REQUIRED CORROBORATION REQUESTED

WAIVER GRANTED CORROBORATION RECEIVEDYES NO YES NO

WAIVER DENIEDSIGNATURE OF CADET DATE REQUEST FOR WAIVER FORWARDED

TO AFROTC/RRFP

APPROVED DISAPPROVED

REMARKS/COUNSELING

SIGNATURE OF AUTHORIZED REPRESENTATIVE GRADE DATE

PREVIOUS EDITIONS ARE OBSOLETE.AFROTC FORM 35, 20100719

ACTION

Cadet has been counseled that his/her conduct will be closely monitored and any future involvements with authorities may result in disenrollmentinvestigation/dismissal. Cadet's initials of acknowledgement: ________

following its

FOR OFFICIAL USE (When filled in)III. CERTIFICATION II


DATE OFINVOLVEMENT




WAS THE USE OF DRUGS ORALCOHOL CITED?

ACTION

NO ACTION REQUIRED CORROBORATION REQUESTED


WAIVER DENIEDSIGNATURE OF CADET DATE REQUEST FOR WAIVER FORWARDED

TO AFROTC/RRFP


REMARKS/COUNSELING


IV. CERTIFICATION III


DATE OFINVOLVEMENT




WAS THE USE OF DRUGS ORALCOHOL CITED?

ACTION

NO ACTION REQUIRED CORROBORATION REQUESTED


WAIVER DENIED REQUEST FOR WAIVER FORWARDEDSIGNATURE OF CADET DATE

TO AFROTC/RRFP


REMARKS/COUNSELING


AFROTC FORM 35, 20100719 REVERSE



RECORD OF EMERGENCY DATA

PRIVACY ACT STATEMENT AUTHORITY: 5 USC 552, 10 USC 655, 1475 to 1480 and 2771, 38 USC 1970, 44 USC 3101, and EO 9397 (SSN). PRINCIPAL PURPOSES: This form is used by military personnel and Department of Defense civilian and contractor personnel, collectively referred to as civilians, when applicable. For military personnel, it is used to designate beneficiaries for certain benefits in the event of the Service member's death. It is also a guide for disposition of that member's pay and allowances if captured, missing or interned. It also shows names and addresses of the person(s) the Service member desires to be notified in case of emergency or death. For civilian personnel, it is used to expedite the notification process in the event of an emergency and/or the death of the member. The purpose of soliciting the SSN is to provide positive identification. All items may not be applicable. ROUTINE USES: None. DISCLOSURE: Voluntary; however, failure to provide accurate personal identifier information and other solicited information will delay notification and the processing of benefits to designated beneficiaries if applicable.

INSTRUCTIONS TO SERVICE MEMBER

This extremely important form is to be used by you to show the names and addresses of your spouse, children, parents, and any other person(s) you would like notified if you become a casualty (other family members or fiance), and, to designate beneficiaries for certain benefits if you die. IT IS YOUR RESPONSIBILITY to keep your Record of Emergency Data up to date to show your desires as to beneficiaries to receive certain death payments, and to show changes in your family or other personnel listed, for example, as a result of marriage, civil court action, death, or address change.

INSTRUCTIONS TO CIVILIANS

This extremely important form is to be used by you to show the names and addresses of your spouse, children, parents, and any other person(s) you would like notified if you become a casualty. Not every item on this form is applicable to you. This form is used by the Department of Defense (DoD) to expedite notification in the case of emergencies or death. It does not have a legal impact on other forms you may have completed with the DoD or your employer.

IMPORTANT: This form is divided into two sections: Section 1 - Emergency Contact Information and Section 2 - Benefits Related Information. READ THE INSTRUCTIONS ON PAGES 3 AND 4 BEFORE COMPLETING THIS FORM.

SECTION 1 - EMERGENCY CONTACT INFORMATION

1. NAME (Last, First, Middle Initial) 2. SSN

3a. SERVICE/CIVILIAN CATEGORY ARMY NAVY MARINE CORPS AIR FORCE DoD CIVILIAN CONTRACTOR

b. REPORTING UNIT CODE/DUTY STATION

4a. SPOUSE NAME (If applicable) (Last, First, Middle Initial) b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

SINGLE DIVORCED WIDOWED

5. CHILDRENa. NAME (Last, First, Middle Initial) b. RELATIONSHIP

c. DATE OF BIRTH(YYYYMMDD) d. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

6a. FATHER NAME (Last, First, Middle Initial) b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

7a. MOTHER NAME (Last, First, Middle Initial) b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

8a. DO NOT NOTIFY DUE TO ILL HEALTH b. NOTIFY INSTEAD

9a. DESIGNATED PERSON(S) (Military only) b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

10. CONTRACTING AGENCY AND TELEPHONE NUMBER (Contractors only)

DD FORM 93, JAN 2008 PREVIOUS EDITION IS OBSOLETE.

SECTION 2 - BENEFITS RELATED INFORMATION

11a. BENEFICIARY(IES) FOR DEATH GRATUITY (Military only)

b. RELATIONSHIP c. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER d. PERCENTAGE

12a. BENEFICIARY(IES) FOR UNPAID PAY/ALLOWANCES (Military only) NAME AND RELATIONSHIP

b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER c. PERCENTAGE

13a. PERSON AUTHORIZED TO DIRECT DISPOSITION (PADD) (Military only) NAME AND RELATIONSHIP

b. ADDRESS (Include ZIP Code) AND TELEPHONE NUMBER

14. CONTINUATION/REMARKS

15. SIGNATURE OF SERVICE MEMBER/CIVILIAN (Include rank, rate, or grade if applicable)

16. SIGNATURE OF WITNESS (Include rank, rate, or grade as appropriate)

17. DATE SIGNED (YYYYMMDD)

DD FORM 93 (BACK), JAN 2008

RESTRICTIONS ON PERSONAL CONDUCT IN THE ARMED FORCES

1. Military life is fundamentally different from civilian life. The military has its own laws, rules, customs, and traditions, including numerousrestrictions on personal behavior, that would not be acceptable in civilian society. These are necessary because military units and personnelmust maintain the high standards of morale, good order, discipline, and unit cohesion that are essential for combat effectiveness.

2. The Armed Forces must be ready at all times for worldwide deployment. Military law and regulations, including the Uniform Code of MilitaryJustice, apply to service members at all times, both on base and off base, from the time the member enters the service until the member isdischarged or otherwise separated from the Armed Forces.

3. Members of the Armed Forces may be involuntarily separated before their term of service ends for various reasons established by law andmilitary regulations, such as:

a. A member may be separated for a pattern of disciplinary infractions, a pattern of misconduct, commission of a serious offense, or civilian conviction.

b. A member who has been referred to a rehabilitation program for personal drug and alcohol abuse may be separated for failure through inability or refusal to participate in, cooperate in, or successfully complete such a program.

c. A member may be discharged by reason of parenthood, if it is determined the member, because of parental responsibilities, is unable to perform his or her duties satisfactorily or is unavailable for worldwide assignment or deployment.

d. A member may be separated for failure to meet service weight control standards or physical fitness standards.

e. A member may be separated for harassment of or violence against any service member.

SIGNATUREDATE OF APPLICATION NAME (Last, First, MI)

SIGNATUREDATE OF ENLISTMENT NAME (Last, First, MI)

SIGNATUREDATE OF COMMISSION NAME (Last, First, MI)

AFROTC FORM 500, 20110804 PREVIOUS EDITIONS ARE OBSOLETE.


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III. REMARKS

IV. APPLICANT CERTIFICATION

I have read the information on this form and understand how it applies to me and my dependent(s). I also understand the needs of the Air Force comefirst and I may be involuntarily discharged should I violate any of these provisions. I certify the information on this form is of my personal knowledge andis true and correct and my recruiter did not advise me to conceal any dependency information.

DATE NAME (Last, First, Middle Initial) SSN SIGNATURE

V. RECRUITER CERTIFICATION

I certify the information on this form was explained to the applicant and I verified the applicant's dependent(s) and marital status from appropriatesource documents.

DATE RECRUITER'S NAME/GRADE SIGNATURE

VI. APPLICANT FINAL CERTIFICATIONOn the date of enlistment or commissioning or appointment and prior to signing the oath, I reviewed the information on this form and hereby reaffirmcomplete knowledge and understanding of the statements contained herein. I further certify all changes to my marital or dependent status sinceinitiation of this form are explained in Section III.DATE SIGNATURE

VII. AIR FORCE REPRESENTATIVE FINAL CERTIFICATION

I have verified all known changes to the applicant's marital or dependent status since initiation of this form and certify they are explained in Section III.DATE NAME/GRADE OF AIR FORCE REPRESENTATIVE SIGNATURE

AF IMT 3010, 19930701, V2 PREVIOUS EDITIONS ARE OBSOLETE.

USAF STATEMENT OF UNDERSTANDING FOR DEPENDENT CARE RESPONSIBILITY(This form is subject to the Privacy Act of 1974. Use Blanket PAS - AF Form 883)

I. MARITAL STATUS

SINGLE MARRIED (Civilian) MARRIED (Military) SEPARATED DIVORCED WIDOWED

II. STATEMENT OF UNDERSTANDINGI understand: My eligibility is based on my marital and dependency status and failure to claim all my dependents may result in my involuntary separ- ation from the Air Force. I have read and understand the following definitions the Air Force considers a dependent for accession purposes. 1. A spouse. 2. Any person under the age of 18 for whom the applicant or spouse has legal or physical custody, control, care, maintenance, or support. includes children from a previous marriage, a relative by blood or marriage and stepchildren or adopted children of the applicant or spouse. 3. Any unmarried natural children of the applicant or spouse regardless of current residence. For male applicants, the term natural child includes those born out of wedlock. 4. Any person who is dependent upon the applicant or spouse for their care, maintenance, or support regardless of age. (5) FOR MALE APPLICANTS ONLY. An unborn child of the spouse or one claimed by or a court order determines is his. It is my responsibility to provide legal documents (marriage certificate, birth certificate, etc.) to substantiate my dependent(s) and it is my responsibility to support myself and my dependent(s) on the pay and allowances I receive. I also understand arrangements for care of my dependent(s) is my personal responsibility and will not interfere with my assigned Air Force duties, including shift work, weekend duty, temporary duty away from my assigned duty station and short notice deploy- ments and evacuations. I further understand my dependent(s) will not prevent me from being available for worldwide assignment and failure to perform my military dependent(s) may result in disciplinary action, to include involuntary discharge. If applying for an enlisted program, my dependent(s) are not permitted to accompany me during basic training, and it is recommended they not accompany me during any technical training. If applying for an officer program, it is strongly recommended my dependent(s) not accompany me while attending training. I also understand government family quarters are assigned based on application date, grade, date of grade, number of dependents, and availability.

Military couples with dependent(s) are required to make dependent care arrangements that allow both members to meet all military obligations and duties. I also understand each member is considered to be serving in his or her own right and must be available for worldwide assignment regardless of marital or dependent status. Additionally, I understand married Air Force couples may apply for a join spouse assignment but there is no guarantee they will be assigned together.

( )

( )

( )

( )

NONE: _________

INSTRUCTIONS

This form is mandatory for all applicants applying for enlistment, commissioning or appointment in the Air Force (AF). Complete inaccordance with AFI 36-2002 and the following instructions:

Section I, Marital Status.

Applicant marks the applicable marital status.

Section II, Statement of Understanding.

Applicant initials all paragraphs to acknowledge his/her understanding. (NOTE: When applicant furnishes proof of permanent transfer of all rights to thelegal, physical, or other responsibility for the custody, control, care, maintenance, and support of a dependant under 18-years of age through formaladoption, they will not be considered a dependant for accession purposes.)

Section III, Remarks.

If a dependency eligibility/waiver is required and approved; list date of approval, approving official, and position. If there are no comments, enter "None"and applicant must initial.

Section IV, Applicant Certification.

Self explanatory.

Section V, Recruiter Certification.

Self explanatory.

Section VI, Applicant Final Certification.

Complete on date of final enlistment, commissioning or appointment. (NOTE: Do not complete at time of delayed enlistment program (DEP) entry.)Ensure all changes to applicant's marital and dependent status are annotated in Section III.

Section VII, Air Force Representative.

Complete on date of final enlistment, commissioning, or appointment. (NOTE: Do not complete at time of DEP entry.) Ensure all changes to applicant'smarital and dependent status are annotated in Section III.

AF IMT 3010, 19930701, V2 (REVERSE)

296 AFROTCI36-2011 1 July 2015

Attachment 14

AIR FORCE DEPENDENCY POLICY STATEMENT OF UNDERSTANDING I _______________________have been briefed on the Air Force policies concerning family care

responsibility and family care responsibility as an AFROTC retention standard. (A family

member is any person over whom I have legal or physical custody or control, or who relies

primarily upon me for their care, maintenance, or support regardless of age). In particular, I

understand the following: a. (Non-contract Cadet) If I am/become unmarried or marry (to include a common-law spouse)

a military member (including another AFROTC cadet), and become responsible for any family

member incapable of self-care I must acquire and maintain an approved Family Care Plan

IAW AFI 36-2908, Family Care Plans, that will adequately cover my time in AFROTC. If I am

unable or unwilling to create or maintain such a family care plan, I will no longer meet AFROTC

retention standards. In such a case, I would then be subject to disenrollment from AFROTC for

failure to maintain military retention standards. If I am disenrolled, I will also be subject to

recoupment of my scholarship benefits.

b. (Contract Cadet) If I am disenrolled from AFROTC after becoming a contract cadet I am

subject to call to EAD in my enlisted grade, recoupment of scholarship benefits or release. If I

have more than two (three with an approved waiver) dependents incapable of self-care I do not

meet enlisted accession standards and cannot be subject to EAD in my enlisted grade. I can only

be subject to recoupment or release.

1st

Ind, Application

Cadet Signature / Date Cadre Signature

2nd

Ind, Enlistment

Cadet Signature / Date Cadre Signature

NOTE: Cadet and detachment representative must sign statement at time of application.

Statement must be recertified by the cadet and detachment representative at time of enlistment.


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292 AFROTCI36-2011 1 July 2015

Attachment 11

DRUG DEMAND REDUCTION PROGRAM MOU

DEPARTMENT OF THE AIR FORCE

AIR UNIVERSITY (AETC)

MEMORANDUM OF UNDERSTANDING FOR DRUG TESTING POLICY

FOR CADETS PARTICIPATING IN SENIOR RESERVE OFFICER TRAINING CORPS

(SROTC)

By direction of the Secretary of the Air Force, I understand as an Air Force ROTC cadet

participating in a SROTC program, I will be subject to random urinalysis drug testing. I

understand that if I am randomly selected, I must provide the requested sample within the

specified time limits. I understand failure to report for a mandatory urinalysis test will be

considered an Unauthorized Absence (UA) and will result in individual command-directed

screening. I understand that any individual refusing to submit a urinalysis sample or testing

positive on a urinalysis test will be processed for disenrollment or dismissal from Air Force

ROTC or specific officer commissioning program.

________________________________ ____________________________________

Cadet Signature and Date Parent/Guardian Signature and Date

(Only for applicants under legal age of majority.

Must be notarized if not signed in presence of

detachment personnel)

________________________________

Printed Name and Signature Witness (or Notary) and Date


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AIR EDUCATION AND TRAINING COMMAND

DATE: _________

MEMORANDUM FOR CADET

FROM: Air Force Reserve Officer Training Corps (AFROTC) Detachment (Det) 159

SUBJECT: Request and Consent for Release of Student Records

1. In compliance with 10 U.S.C. 2102 et seq., your consent is required to permit the educational

institution in which you are/were enrolled to release official copies of your transcripts of

grades and/or other student records, files, or data that are a part of your student records to

AFROTC and Department of Defense (DOD) agencies, as may be required by these

agencies.

2. It is mutually understood that the purposes of this request for official copies of student

records is necessary for AFROTC screening and evaluation of its present and potential cadet

members and those cadets commissioned or disenrolled from the AFROTC program. It is

further understood that the privacy of the information collected by means of the request will

be maintained in accordance with the Privacy Act of 1974 and the Freedom of Information

Act, and the information will be used for official AFROTC purposes only.

AFROTC Det 159 Representative

1st Ind, Student DATE: __________________

MEMORANDUM FOR AFROTC Det 159

I have read and understand your request for official copies of my school records. I hereby

voluntarily consent to the release of such official records as you may require in your above-

stated request and have signed the attached authorization for appropriate school officials to

release to Det 159 personnel or to the appropriate DOD agency any and all official records,

files, and data for their use as requested above.

(Student’s Signature) (Parent’s Signature if student is under age 18 years of age)

Attachment:

Consent for Release of Student Records


AIR EDUCATION AND TRAINING COMMAND

DATE: _________

MEMORANDUM FOR UNIVERSITY OF CENTRAL FLORIDA

FROM: Cadet ______________________________

SUBJECT: Consent for Release of Student Records

In compliance with 10 U.S.C. 2102 et seq., I hereby voluntarily consent to the release of such

official records as may be required by Air Force Reserve Officer Training Corps (AFROTC)

Headquarters and AFROTC Detachment (Det) 159 to conduct official AFROTC business. I

therefore authorize appropriate school officials to release to Det 159 personnel or to the

appropriate DOD agency any and all official records, files, and data for their use in official

AFROTC business.

(Student’s Signature) (Parent’s Signature if student is under age 18 years of age)


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AFROTC Detachment 159 (AETC)

University of Central Florida

Orlando, FL 32816

MEMORANDUM FOR AIR FORCE CENTRAL ADJUDICATION AUTHORITY

FROM: AFROTC/Detachment 159

PO Box 162380

Classroom II, Room 221

Orlando, FL 32816-2380

SUBJECT: Dual Citizenship Renouncement Statement and Proof of Passport Destruction

1. In order to commission through HQ AFROTC and be granted a security clearance a cadet must

show willingness to renounce their dual citizenship, if applicable, and destroy their foreign passport.

The written memorandum will be forwarded to Air Force Central Adjudication Facility at:

AFCAF/PSA, 229 Brookley Ave, Bolling AFB 20032.

2. This memorandum is provided for:

(Last, First, M.I.):_________________________________ SSN:______________________.

Who shows his/her willingness to renounce citizenship from:_______________________________

and has taken the applicable steps per AFI 31-501 para 5.7.4 through 5.7.5.

Cadet, AFROTC Det 159

3. The witnessing Security Manager will annotate in this area of the memorandum, the destruction

of the passport IAW AFI 31-501 para 5.7.3.2 and provide a copy of this memorandum to the cadet.

BRIANNA R. HORTON, TSgt, USAF

Unit Security Manager, AFROTC Det 159

Office use only: WINGS verified by:_____________________ Date:_______________


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INSTRUCTIONS FOR COMPLETING THE ACADEMIC PLAN

PURPOSE: This form will be used throughout your AFROTC membership. The form gives a tentative schedule of courses required for your graduation and is used as a source document for your Date of Graduation and Date of Commissioning.

GENERAL INSTRUCTIONS: Complete the term schedules in pencil to facilitate correction to course load due to availability of classes. However, all signatures must be in ink. Complete the form beginning in the current semester. Previous courses and semester do not need to be identified.

PART I

Block 1 - Enter Last Name, First Name, MI Block 2 - Verify school awarding bachelor’s degree and detachment (Det 159) Block 3 – Verify academic major Block 4 - Institutional official (usually your academic advisor) will enter the following information:

The type of degree and term of completion. (i.e. a BA degree after Spring 17 term)

Signature and date.

By signing the form the institutional official is confirming that the tentative plan will result in completion of a degree. The institutional official is also confirming the courses, credit hours attempted, and hours towards degree are accurate.

Block 5 - Initial AFROTC Review - This block will be completed by the AFROTC adviser after the form is completed.

PART II - Complete the Term, Year, Course Number, Course Title, and Credit Hours Attempt block for each semester. Begin with the current semester. Ensure all semesters, including all summer terms even if you are not taking any courses, are listed up to and including the graduating term. DO NOT COMPLETE SHADED AREAS. These sections will be completed by the AFROTC advisor during term reviews. Each fall semester you will need to have your university official (usually your academic advisor) sign off on this form. They will do this in the remarks section. Remember to include your AFROTC classes in your academic plan. For Fall and Spring you must have a minimum of 12 hours per semester to be a active Cadet.

CH Term Fall Classes CH Term Spring Classes

1 AFR 1101C The Air Force Today I 1 AFR 1111C The Air Force Today II

1 AFR 2130C The Development of Air Power I 1 AFR 2131C The Development of Air Power II

3 AFR 3220C Air Force Leadership and Management I 3 AFR 3230C Air Force Leadership and

Management II

3 AFR 4201C National Security Forces in Contemporary American Society I 3 AFR 4210C National Security Forces in

Contemporary American Society II CH – Credit Hours Term – Term you’ll take class

Examples:

As a freshman register for AFR1101C in the fall and AFR1111C in the spring, etc.

As a sophomore, first semester in the fall, register for AFR1101C and 2130C in the fall and AFR 1111C and 2131C in the spring. After field training take one class per semester.

As a freshman or sophomore, first semester in the spring, register for AFR 1111C in the spring, AFR1101C and 2130C in the fall and 2131C in the spring before field training. After field training take one class per semester.

If you are trying to go to Field Training this next summer and your first semester will be in the spring then you will sign up for AFR 2131C. This is a special case, see a cadre member for details.

If your situation is not covered, see a cadre member before you complete your Form 48.

AFROTC IMT 48 (Det 159) PLANNED ACADEMIC PROGRAM PAGE ____ OF ____

Student Signature AFROTC Reviewer Signature/Date

Student Signature / Date

Course Number Credit Hours Attempt

Credit Hours Comp

Deviations


Credit Hours Comp

Deviations

Signature/Date of Institution Official

Total credit hours

Term: YearCourse Title

Total credit hours


Remarks: Fall Term Reevaluation Complete: ______________________________________

II. ACADEMIC PLAN / TERM REVIEWTerm: Year

Course Title


Signature/Date of Institution Official Remarks:

6. DEGREE CERTIFICATION

DO NOT SIGN UNTIL GRADUATION. I CERTIFY THAT I HAVE SUCCESSFULLY COMPLETED ALL DEGREE REQUIREMENTS AND WILL GRADUATE AS STATED IN BLOCK 4.

5. INITIAL AFROTC REVIEW

COMPLETION OF THIS EDUCATION PLAN SHOULD RESULT IN

MY OBTAINING A BS BA OTHER ______________ (List)

DEGREE AT THE END OF THE _________ MONTH ________ Year

4. INSTITUTIONAL OFFICIAL REVIEWInstitution Official Signature/Date

I. ADMINISTRATIVE DATA3. Academic Major/Code2. Academic Institution / AFROTC Det1. Name (Last, First MI)

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/ Det 159

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Accepted set by JHallett

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Unmarked set by JHallett

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Accepted set by JHallett

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None set by JHallett



Credit Hours Comp

Deviations



Credit Hours Comp

Deviations


Course Title

Fall Term Reevaluation Complete: ______________________________________


Remarks:


Term: Year

Total credit hours

Total credit hoursRemarks:





Credit Hours Comp

Deviations



Credit Hours Comp

Deviations


FRONT

Course TitleTerm: Year




Total credit hours


AFROTC Reviewer Signature/Date

Remarks:

Student Signature




Credit Hours Comp

Deviations



Credit Hours Comp

Deviations


BACK











Credit Hours Comp

Deviations



Credit Hours Comp

Deviations


FRONT

Course TitleYearTerm:

Remarks:Total credit hours


AFROTC Reviewer Signature/DateStudent Signature



Fall Term Reevaluation Complete: ______________________________________Remarks:Total credit hours



Credit Hours Comp

Deviations



Credit Hours Comp

Deviations


BACK


Remarks:Total credit hours





Fall Term Reevaluation Complete: ______________________________________Remarks:Total credit hours

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