Fillable Printable Valley Forge Military College Army ROTC Application for Early Commissioning Program
Fillable Printable Valley Forge Military College Army ROTC Application for Early Commissioning Program
Valley Forge Military College Army ROTC Application for Early Commissioning Program
Valley Forge Military College
Army ROTC Application for
Early Commissioning Program
Submit this completed application form with your original birth certificate to:
Valley Forge Military College
Army ROTC
1001 Eagle Road
Wayne, PA 19087
Instructions: Print this form using Adobe Acrobat reader to fill in all the information electronically.
Submit form along with your original birth certificate to the address below. Please feel free to
p
lace a collect phone call to (610) 687-9495 if you have any questions. This application in no way
commits you to military service.
Type or Print Clearly:
N
ame:______________________________________________________________
Local Address: ______________________________________________________________________
Home Phone: _____________________________ E-Mail Address: __________________________________
Date of Birth: _____________________________ Social Security Number: ____________________________
Place of Birth: ___________________________________________________ U.S. Citizen: Yes ____ No ____
Academic Info:
High School Attended: _________________________________________________________________
High School Address: __________________________________________________________________
High School Phone number: ____________________________ High School Graduation Date: ___________
High School guidance Counselor’s Name:_____________________________________________________
JROTC Participation: Yes ____ No ____ If Yes, for how long?
Senior Army Instructor’s Name: _______________________________________________________
Prior Service: Yes ____ No ____ If yes, please indicate the following:
Active _____ Reserves ______ National Guard ______
If discharged, enter Reenlistment Code here: ____________
Unit Name: ____________________________________________ Unit Phone: ________________________
Unit Address: ________________________________________________________________________
Please forward a copy of one of the following, as appropriate:
DD Form 4 (Guard and Reserve only) DA Form 220 DD Form 214
Height: _______ Weight: _______ Hat Size: _____ Shoe Size: _____ T-Shirt Size: _____
Do you now or have you had any civil or criminal convictions? Yes* ___ No ___
* If you checked “Yes” above, sub mit a state me nt of facts on a separate sheet of paper that includes
circumsta nce s, dates, actions, charges, results and satis faction of sentence. Traffic tickets in excess
of six per year or one totaling $250 or more requires a statement and/or waiver. (Note: Application will not be processed witout statement.)
Have you applied for a three-year or four-year ROTC Scholarship? Yes ___ No ___
Have you taken a DODMERB Physical? Yes ___ No ___
You will be:
(must check one)
____ Attending the ROTC Leaders Training Course
____ Enlisting in the Guard/Reserve for Basic Training
Note: In order to better prepare high school graduates for ROTC , we conduct
a Leaders Training Course at VFMC for four days prior to the cadets’ departure
for Fort Knox, KY. Please provide the following information if you would like
to attend so that we may make travel arrangements. The Army covers travel
expenses to and from the Leaders Training Course .
My travel plans to VFMC to attend Leaders Training Course are as follows:
Automobile (if within 90 minutes): ____ Army-paid flight: ____
Airport I prefer to leave from and return to is: ______________________
I certify that all information provided within this document is true and correct to the best of
my knowledge. I submit this application subject to the penalties of Pennsylvania Criminal
Code, Title 18, Section 4904, relating to unsworn falsification to authorities. I understand
that if I have withheld or given false information, I may be denied admission or dismissed
from the Army ROTC program at Valley Forge Military College.
Signature: ___________________________________________ Date: _______________
DATA REQUIRED BY THE PRIVACY ACT OF 1974:
1. Authority: Title 10 USC 3012 (Section 2101 and 2111)
2. Princip le Purpo se: To obtain infor mation to determine eligibilit y for participation in the Army ROTC
Program; to provide information necessary for processing B asic Ca mp and advanced ROTC applications.
3. Routi ne Uses: T o provide information on address and telephone numbers to facilitate contact with the
candidate and his/her fa mily; to make matter of record the physical characteristics of the candidate; to
pro vide information essential for a fair evaluation of the cand id a te’s acceptability for Basic Camp attendance
or advanced ROTC pa rticipation.
4. Mandatory or Voluntary Disclosure and Effect on Individua l: Disclosure of Social Sec urity Number is
mandatory and required for identification. Failure to provide Social Security Number will preclude
pro cessing of the candidate’s applica tion. Disclosur e o f all other information is voluntary; however, fail ure
to p rovide all of the voluntary in formation may d e lay or prevent pr ocessing o f applications for Basic Camp
or entry into the ROT C advanced course.
Personal Data:
VFMC Army ROTC Program Application for ECP, page 2
ROTC Scholarship Applic ant Snapshot
Data required by the Privacy Act of 1974
1 . Auth ori ty: 10 USC 21 01 an d 21 07 2. Principal P urpose(s) To physically ide ntify e ac h app lican t 3. Routi ne Use s : To be use d by
the ROTC selection boar d in consideration of the app licant. 4. Manda tory or v oluntary d isclosure and eff ect on the in dividual for
n ot provid ing the information: Use of t his form is mandatory, applicant may not be conside red if pic ture is not submit ted.
A ttach recent snapshot
( with in l ast 3 month s )
Fu ll le ngth pre fe rre d ,
at l e as t kne es up
Signature o f Applic an t: ___ _____ __ __ __ ___ __ __ ____ __ ___ __ __ _____ _
Name: __________________________________________ SSN: ________________
Current Height: ____ ___ __ __ _ Cur ren t We igh t: ___ _____ __ __ ___ _
Mon th and Ye a r o f Ph oto: ___ __ __ __ ___ __ __ __ ____ __
Modifie d ROTC Cadet Com mand Form 103-R, F eb 89
E xtracu rricular/A thletic/
L ead ersh ip A ctivities Record
V a lley Forge M ilitary College Army RO TC S cholarship Applica tion
Nam e (Last, Fi rst, Middle)
_________________________
SSN: ____________________
A. Instructions Indicate below your participation in extracurricular, athletic and leadership activities.
Any recognized activity not listed should be in “other.” Be certain to indicate all leadership
positions held. If additional space is needed, use the space provided in section E.
In section D list all after school work.
Date and sign the form in bloc k F.
B . Athletic Activities Chec k B ox if none.
Sports
Baseball / softba ll
Basketball
Boxing
Football
Golf
Gymnastics
Hockey
So ccer
Swimming
Track
Tenni s
Wrestling
R i fle team
Other (explain)
C. Extracurricular Activities Che ck box if none.
Type # of years Succe ss A chieved
(Awards, positions of leadershi p, etc.)
Church Gro up
Debate
Dramat ics
Scholastic Societies
School Band
School Newspaper
Student Government
Yearbook
Drill Team
Agriculture
S ocial Fr ate rniti es
Junio r ROTC
Other (explain)
Memb er
Lette r
Cap tain
All district
Grade Grade Grade Grade
Member
Letter
Cap tain
All district
Member
Letter
Captain
All distri ct
Me m be r
Letter
Captain
All district
Modified RO TC C ade t C omman d Form 105-R , OCT 91
D. After School Work
1. T ype of Work Number of hours each week
2. Sum mer Employmen t
E. Continuation: (I dentify item s being continued.)
F. Date: Signatu r e of Applica n t
A pplican t’s Personal State m en t
Nam e (Last, First, Mi ddle) SSN:
State belo w in your o wn wo rds why you desire to receive a co mmission as an A rmy Officer .
Signature Date
M odi fied ROTC Cadet C omm and Form 166-R , O ct 94
SUBJECT: Request for Transcr ipt
TH R U: Prof e sso r of Military Science
U.S. A rmy ROTC Instructor Gro up
Valley Forge military College
Way n e, Pa 190 87 -369 5
TO: Guidance Office/Student Reco rds
(name of high school)
(address of high school)
Please ma il one copy of my c omp lete transcr ip t to t he ab ove ins titution. If transcr ipt does not
provide an explanation of credit ho urs an d com putation of grade point av erage, please attach an
explanation. The tran script should reflect completion of high school or a college degree program.
If an official transcr ipt is not yet availab le for the last t erm, please include a stat ement r eflecting
courses co m pleted and grades received for that term.
I am awar e o f my right s u nder t h e Fa mily Ed ucat i o n Right s and the Priv acy Act o f 19 74 . T his
letter autho rizes you to release a copy of my academic records to any one within th e Department
of Defense.
I wo ul d appreciate your prom pt respon se to this request. Thank you.
____________________________________
(pr int name)
____________________________________
(signature)
______________________
(social security num ber)
_______________________
(class / date of gra duation)
SUBJECT: Request for Transcr ipt
TH R U: Prof e sso r of Military Science
U.S. A rmy ROTC Instructor Gro up
Valley Forge military College
Way n e, Pa 190 87 -369 5
TO: Guidance Office/Student Reco rds
(name of high school)
(address of high school)
Please ma il one copy of my c omp lete transcr ip t to t he ab ove ins titution. If transcr ipt does not
provide an explanation of credit ho urs an d com putation of grade point av erage, please attach an
explanation. The tran script should reflect completion of high school or a college degree program.
If an official transcr ipt is not yet availab le for the last t erm, please include a stat ement r eflecting
courses co m pleted and grades received for that term.
I am awar e o f my right s u nder t h e Fa mily Ed ucat i o n Right s and the Priv acy Act o f 19 74 . T his
letter autho rizes you to release a copy of my academic records to any one within th e Department
of Defense.
I wo ul d appreciate your prom pt respon se to this request. Thank you.
____________________________________
(pr int name)
____________________________________
(signature)
______________________
(social security num ber)
_______________________
(class / date of gra duation)
