Fillable Printable U.S. Army ROTC 4-Year College Scholarship Application
Fillable Printable U.S. Army ROTC 4-Year College Scholarship Application
U.S. Army ROTC 4-Year College Scholarship Application
PLEASE READ THE FOLLOWING STATEMENT REQUIRED BY THE PRIVACY
ACT OF 1974 BEFORE COMPLETING THE APPLICATION.
1. AUTHORITY: Title 50, Appendix U.S.C., Public Law 96-357 96th Congress,
September 24, 1980 (Amendment to 10 U.S.C. 2107).
2. PRINCIPAL PURPOSES(S): To administer the financial assistance
program; to select recipients for 2, 3, 4-year scholarships, to monitor
selectee's academic and ROTC performance; to develop policies and
procedures, compile statistics and render analytical reports, and; to
provide Army Professors of Military Science and university Admission
Officials the names, addresses and academic data of all scholarship
applicants for recruitment purposes.
3. ROUTINE USES: The information provided on the application will be
used to screen and select individuals to receive ROTC Scholarships, to
maintain data on the scholarship program, to compare scholarship
applicants to others on active duty and to provide academic data, names
and addresses of applicants to Professors of Military Science and
Admission Officials at colleges and universities so that they can contact
applicants for recruitment purposes.
4. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL
PROVIDING INFORMATION: Disclosure of information requested in
CC FORM 114-R is voluntary. However, the information must be furnished
for applicant to receive consideration for an ROTC scholarship.
CC FORM 114-R, AUG 08 PREVIOUS EDITIONS ARE OBSOLETE
PRIVACY ACT STATEMENT
USE A BLACK BALL POINT PEN TO COMPLETE APPLICATION
Scholarship Application
U.S. Army ROTC
4-Year College
(For High School Students)
IT IS YOUR RESPONSIBILITY TO ENSURE THAT YOUR APPLICATION IS COMPLETE.
THE FOLLOWING CHECKLIST IS PROVIDED TO ASSIST YOU IN REVIEWING YOU
R
APPLICATION FOR COMPLETENESS:
Personal Information Page 1 Completed
(name, SSN, address, phone #)
Personal Information Page 2 Completed
(parent/Guardian Info, height/weight)
Personal Information Page 3 Completed
(High School Info, SAT/ACT, CGPA)
Request for Transcript Printed?
Date Transcript Faxed to HQCC (757) 788-5781
Date Transcript scanned and e-mailed to HQCC: [email protected]
Date copies of SAT/ACT scores Mailed to HQCC
Date copies of SAT/ACT scores Faxed to HQCC (757) 788-5781
Date copies of SAT/ACT scores scanned and e-mailed to HQCC E-Mail Address:
Personal Information Page 4 Completed (sex, race, marital status, dependents)
Personal Information Page 1 Completed (name, SSN, address, phone #)
Personal Information Page 2 Completed (parent/Guardian Info, height/weight)
Personal Information Page 3 Completed (High School Info, SAT/ACT, CGPA)
Request for Transcript Printed?
Date Transcript Faxed to HQCC (757) 788-5781
Date Transcript scanned and e-mailed to HQCC: [email protected]
Date copies of SAT/ACT scores Mailed to HQCC
Date copies of SAT/ACT scores Faxed to HQCC (757) 788-5781
Date copies of SAT/ACT scores scanned and e-mailed to HQCC E-Mail Address:
Personal Information Page 4 Completed (sex, race, marital status, dependents)
U.S. Army ROTC 4-Year College Scholarship
Applicant Checklist
(For High School Students)
HQCC, ATTN: Scholarship Branch, BLDG 56, 55 Patch Rd, Ft Monroe, VA 23651
USE A BLACK BALL POINT PEN TO COMPLETE APPLICATION
Date Transcript Mailed to HQCC
HQCC, ATTN: Scholarship Branch, BLDG 56, 55 Patch Rd, Ft Monroe, VA
HQCC, ATTN Scholarship Branch, Bldg 56, 55 Patch Rd, Ft Mon
r
HQCC, ATTN Scholarship Branch, Bldg 56, 55 Patch Rd, Ft Monroe, VA 23651
Date Transcript Mailed to HQCC
1.
(Complete this block on every page of the application to ensure accurate processing)
2. MI
3. Ext
(Jr, Sr)
4.
5.
6
.
First Name
Last Name
Second Line Street Address (if required)
SAT- Math
SAT- Writing
Form Approved -
OMB No. 0702-0073
Expires 06/30/2009
U.S. Army ROTC 4-Year College Scholarship Application - (For High School Students)
PART I - PERSONAL DATA
SSN
This form can be downloaded as a MS-Excel spreadsheet and E-mailed to [email protected]. Go to www.goarmy.com/rotc, click on Scholarships, click on
High School Students, scroll down and click on Download an application in EXCEL format.
The public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington
Headquarters Services, Directorate for Information Operations and Reports (0702-0073), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 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 a collection of
information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR APPLICATION TO THE ABOVE ADDRESS. RETURN
COMPLETED APPLICATION TO The U.S. Army ROTC Scholarship, U.S. Army Cadet Command , Fort Monroe, VA 23651-1052
Street Address
10. Educational Testing Scores
SAT-Verbal
ACT-English
ACT-Math
Cit
y
ACT Reading
6
.
7. 8. 9.
Number of Semesters
Your 9-digit ZIPCODE is mandatory; check with your local Post Office
American Indian or Alaska Native
Asian
Black or African American
U.S. Citizen/National
Hispanic or Latino
Non U.S. Citizen
Not Hispanic or Latino
Pending Citizenship
Native Hawaiian or Other Pacific Islander
19. Military Status White
Other
20. Marital Status 21. Dependency Status
Single No Children
Married 1-3 Children
Not Applicable
Divorced More than 3 Children
CC FORM 114-R, Aug 08
PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 6
Overseas, start with country code; within U.S., start with area code
ACT-Nat Science
15. Weight
(lbs)
11. HS CGPA
16. Race -
Check all blocks that apply
18. U.S. Citizenship
17. Telephone Number
(commercial only) (DO NOT INCLUDE ANY DASHES
OR SPECIAL CHARACTERS)
12. Birth Date (YYYY/MM/DD) 13. Sex (M/F) 14. Height (Inches)
Zip Code
ACT-Writing
Foreign Address Code
Served on Active Duty from which you were discharged or separated to civilian status. You
must provide a copy of your DD Form 214.
Currently on full-time Active Duty Military Service. ETS Date is
State
City
ACT
-
R
ea
di
n
g
Basic Active Service Date (BASD) is
22.
I desire to compete for an ROTC HBCU Scholarship
I am not interested in an ROTC HBCU Scholarship
No
25.
26.
27.
28.
29.
32.
Internet - armyrotc.com
Internet - goarmy.com
CC FORM 114-R, Aug 08
Page 2 of 6
PART I - PERSONAL DATA (Continued)
SSN
Personal E-Mail Address
Address of High School Currently Attending
Second Line Address of High School Currently Attending (if required)
I desire to compete for admission to the U.S. Military
Academy at West Point (Cadet Command will share
application information with USMA electronically)
PART II - HIGH SCHOOL DATA
Name of High School Currently Attending
23. Desire to compete for a scholarship to an HBCU or to compete
for USMA
24. Have you ever been arrested, convicted or fined for any violation of Law?
Yes- If Yes, please give a complete description of the incident (name and place
of court, nature of offense, date, disposition, and the amount of the fine
imposed) in an electronic word processing document and E-mail to
[email protected]. Be sure to include your full name and SSN.
Overseas, start with country code; within U.S., start with area code
ETS Code 33. High School E-Mail Address
31. Telephone Number
(commercial only)
City
State 30. Zip Code
Letter
34. What influenced you to request an Army ROTC Scholarship Application?
Magazine Advertisement ROTC Office Poster
National Society of
Professional Engineers
Newspaper Radio/Television Military Officer
Other - Indicate below
Brochure Friend Parents
School Officials ROTC Recruiters
Enter a 3-digit Academic Discipline Code
NOTE:
If you select Nursing Discipline, you must attend
Universities provided in this packet.
If you select Engineering Discipline, you must
attend an accredited university.
CC FORM 114-R, Aug 08
Page 3 of 6
PART III - SCHOOL OF INTENT DATA
SSN
35. Major Subject - Scholarships are awarded by
academic discipline, so please select carefully.
Refer to the Academic Discipline List provided in this
packet.
36. School Choices - List the code for each school choice from the list in your booklet. Write the name in the
space provided.
Choice School FICE Code School Name
3rd
4th
1st
2nd
6th
7th
a Designated Nursing School annotated with a "N"
on the list of Army ROTC Colleges and
5th
10th
37. Remarks Section - Please expound on any of the above information outlining scholastic, athletic, and leadership achievements not otherwise annotated. You may
also type your remarks in a word processing document and E-mail to [email protected]. Be sure to include your name and SSN.
8th
9th
38.
Grade 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12 10 11 12
Activity
Baseball/Softball
Basketball
Rifle/Pistol
Cross Country/Track
Football
Golf
Gymnastics
Hockey/Lacrosse
Skiing
Soccer
Swimming/Diving
Tennis
Volleyball
Wrestling/Judo/Karate
Other Sport
Name of Other Sport
CC FORM 114-R, Aug 08
Page 4 of 6
PART IV - ACTIVITIES DATA
SSN
Athletic Activities - Please indicate all in which you participated with an "X" in the box under the appropriate Grade in School
F. City/County
Organized Leagues
A. JV B. Varsity C. Letter D. Captain E. All State
39.
School Officers 10 11 12 10 11 12 10 11 12
President/Chairperson
Vice President
Secretary/Treasurer
D. Publications 10 11 12
E.
10 11 12 10 11 12 10 11 12
Editor in Chief
* Identify award type and name in Remarks Item 36
F. Other Activities 10 11 12 10 11 12 10 11 12
Drill Team 4H Club Judge Debate Team or Squad
Sea Cadet Member Camp Counselor
Church Group Coach
Church Group Ldr/Director Tech/Lab Asst
Cheerleader/Pom Pom Two or More Public Speeches Member USAR
NCO USAR
Junior Achievement Language Participation Member ARNG
Which Language?
G. Organizations Pres VP H. Music Participation
Boys'/Girls' Nation
10 11 12 10 11 12 10 11 12
Gov Lt Gov Delegate Membe
r
Boys'/Girls' State
I. Boy Scouts 10 11 12 K. Girl Scouts 10 11 12
Pres VP Member
Membe
r
Membe
r
National Honor Society Jr Ass't Scoutmaster Patrol Leader
Eagle Troop Officer
Pres VP Member
Ass't Scoutmaster Ass't Leader
Beta Club Sr Patrol Leader Attended Wider Ops
Troop Leader Gold Award
CC FORM 114-R, Aug 08
Page 5 of 6
PART IV - ACTIVITIES DATA (Continued)
SSN
Other Organized Activities - Please indicate all in which you participated with an "X" in the box under the appropriate Grade in School
A. Student Body/Government B. Class C. School Club
Other - Specify in
Remarks (Item 36)
Other - Specify in
Remarks (Item 36)
(List Type of Club in
Remarks Item 36)
Representative/
Committee
Chairperson
Scholastic Awards
and Honors*
Athletic Awards and
Honors*
Leadership Awards
& Honors*
Other - Specify in
Remarks (Item 36)
Writer-Reporter or
other Staff Member
Theater/Play Actor/Actress,
Stage Manager or Student
Director in a 3 ACT play before a
public audience
Master of Ceremonies/
Chairperson of Panel
County, City or
Local: e.g. Amer
Legion Citizenship
County, City or
Local: e.g. Amer
Legion Citizenship
County, City or
Local: e.g. Amer
Legion Citizenship
Business,
Circulation or
Advertising Mgr
National or State:
e.g. All-State
Band/Orchestra/
Chorus
National or State:
e.g. All-State
Band/Orchestra/
Chorus
National or State:
e.g. All-State
Band/Orchestra/
Chorus
Feature, Sports,
News, or Photo
Editor
Di
rec
t
or,
L
ea
d
er or
Drum Major
NCO ARNG
Member Orchestra Band Chorus
39. M. Junior ROTC
Horizon Club Member Member 10 11 12
Ass't Leader Billy Mitchell Award Army
Camp Counselor Officer
Amelia Earhart Award
10 11 12 10 11 12 10 11 12
9 Hours or Less 20-29 Hours More than 40 Hours
10-19 Hours 30-39 Hours
41. Parent/Guardian Information (complete ALL items)
M
r
/M
rs
/Ms
Fi
rs
t
N
ame
MI
Last Name
Ext
(Jr, Sr)
Street Address
City State Zip Code
Parents E-Mail Address
CC FORM 114-R
,
Au
g
08
Page 6 of 6
PART IV - ACTIVITIES DATA (Continued)
SSN
(Continued)
J. Camp Fire, Inc
K. Civil Air Patrol
Participation
L. Higher Education
Attendance
Prep School Above the
High School Level OfficerRep/National Meetings
O
t
h
er -
S
pec
if
y
i
n
Remarks (Item 36)
Navy
Attended
College/Currently
Attending College
C
redit
Hours
Member
(NCO - Noncommissioned Officer)
40. If you worked on School Days during the entire school year, either at a paying job, on a farm or in volunteer community work, indicate the grade you were in by the
number of hours worked each week.
PART V - PERSONAL STATEMENT/CERTIFICATION
(
Initials
)
Date
43. CERTIFICATION STATEMENT: By placing my initials on the line below, I certify that all the information is complete and correct to the best of my knowledge. I have no
convictions or beliefs which would prohibit my serving in an unrestricted military status.
42. PERSONAL STATEMENT: Consider carefully and then state below in the space provided why you wish to enroll in the Army ROTC program. Indicate in your statement
how you believe your own objectives in life are related to the education and training offered by Army ROTC and what a career obligation means to you.
DO NOT USE Continuation Sheets.
Rep/Regional Meetings
Member Local
C
ouncil
Board
A
ir
Force NCO
Authority 10 USC 2101, 2103, 2104, 2107, 2107A, 2111 and 5 USC 301.2
Principal Purpose To request applicant's secondary school transcript for use in determining scholarship eligibility.
Routine Uses Capturing scholarship applicant's secondary school progress. Once completed by the school
guidance counselor, this form is used in determining the applicant's eligibility for a scholarship.
Disclosure Disclosure of the information requested in this endorsement is voluntary. However, applicable
portions must be completed if the applicant desires to be considered for an Army Senior ROTC
Scholarship.
1. NAME OF APPLICANT
(Last, First, Middle)
2. SOCIAL SECURITY NUMBER
3. BIRTH DATE
(YY MM DD)
4. YEAR OF GRADUATION 5. HIGH SCHOOL NAME AND ETS CODE
The student named above is applying for an Army ROTC 4-Year Scholarship. Please complete this part of the form as accurately
as possible. A transcript of grades is required in reviewing the applicant's record to determine scholarship eligibility.
A. In addition to courses taken (or in progress) and grades received, it is essential that the transcript reflect rank in class along
with the most complete academic record to include test results such as ACT's, SAT's, and other national examinations.
B. IMPORTANT! Please submit this information immediately.
C. Return completed form and a transcript signed or stamped by a high school official to: HQs, Cadet Command ATTN: ATCC-OP-I-S
(Scholarships), 55 Patch Rd., Bldg. 56, Fort Monroe, VA 23651-1052 or email to [email protected], or fax to (757) 788-5781.
D. I authorize release of my high school transcript.
APPLICANT SIGNATURE DATE
7. RANK IN CLASS
(Approximate to nearest 10th from top)
(T
o neares
t
10th
.
Pl
ease conver
t
t
o a
4
.
0
GPA
S
ca
l
e
)
EXACTLY APPROXIMATELY
4-YEAR COLLEGE
RANK FROM TOP NUMBER OF STUDENTS
2-YEAR COLLEGE
9. Did this student take any of the following:
Not Offered Yes No
Honors Courses
Accelerated Courses
Advanced Placement Courses
10. Are all honors accelerated and advanced placement courses given extra credit in computing:
Yes No
Rank in Class
Grade Averages
11. Official School Name
School Address
City State Zip Code
School telephone number (include area code)
School E-Mail address
CC FORM 168-R, AUG 2006 PREVIOUS EDITIONS ARE OBSOLETE
U.S. ARMY ROTC 4-YEAR SCHOLARSHIP APPLICATION
REQUEST FOR SECONDARY SCHOOL TRANSCRIPT
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
PERSONAL DATA
8. % GRAD CLASS EXPECTED TO ENTER
SCHOLASTIC/BACKGROUND DATA
6. CUMULATIVE GRADE POINT AVERAGE
12. Ranking Period
From To
Indicate how grade point average and rank were determined if profile not available
13. If rank is not available, please indicate placement by percentile below:
Top 5% Top 10% Top 20% Top 30% Top 40% Top 50% Lower 50%
14. Comment: (Additional information which may be significant in considering applicant)
DATE TITLE SIGNATURE PRINT NAME
CC FORM 168-R, AUG 2006 PREVIOUS EDITIONS ARE OBSOLETE
U.S. ARMY ROTC 4-YEAR SCHOLARSHIP APPLICATION
REQUEST FOR SECONDARY SCHOOL TRANSCRIPT
SCHOLASTIC/BACKGROUND DATA (continued)
