OmniForm Form - Virginia Tech Naval ROTC

Print out SINGLE sided only. Do not print out on both sides of the paper.
Do not sign or date any forms.
College Program Paperwork
Name All Caps
Last, First, Middle
Social Security Number
Home of Record
Birth Date YYYYMMDD
Student ID#
&HOO3KRQH1XPEHU
VT Email Address
(NROTC STAFF) Have they provided:
Birth Certificate/Passport (SSN Card for Marines)
Direct Deposit Information
Physical
Do not sign or date any forms.
STUDENT FILE INDEX
NAME (Last, First MI)
STATUS:
Scholarship
STA-21 / MECEP
Navy
College Program
SSOP/ USNR
Marine Corps
NROTC Honor Code (NSTC 1533/121) – Original
Disclosure Accounting Form (OPNAV 5211/9)
NROTC Acceptance and Oath of Office (NSTC 1533/126)
(Scholarship only)
Individual NROTC Education Program Cost (NSTC 1533/113)
Original (Scholarship Only)
Dependency Application/Record of Emergency Data (NAVPERS
1070/602) w/SGLI Election (SGLV 8286)
- First and Third Copies
Birth Certificate (Certified to be a True Copy)
Copies of official correspondence originated at the unit and
endorsements (LOA letters, probation letters, etc.)
Certificate of Naturalization
- May use Certificate of Proof of Citizenship of Foreign Born
Applicants for Enlisted (NAVMC 538) or Letter of Certification
sighting Naturalization Papers
Orders, or copies thereof, with all endorsements (less any LES)
Tattoo screening form, Navy or Marine Corps as appropriate
Locally completed NROTC Scholarship/College Program Application
IRR Notification statement (1/C Midshipman only)
Check applicable:
____ NROTC 4-Year ASR Form (NSTC 1533/106)
____ NSTC - Controlled Scholarship Letter
____ NROTC College Program Application (NSTC 1533/133)
*Destroy Interviewer’s Appraisal Sheets
Drug and Alcohol Abuse Statement of Understanding (OPNAV
5350/1) - Original
NROTC Scholarship Service Agreement (NSTC 1533/135)
or NROTC College Program Advanced Standing Service Agreement
(NSTC 1533/127) - Original
NROTC Service Agreement Review (NSTC 1533/132)
Enlistment/Reenlistment Agreement(s) (DD Form 4)
- Agreement to Extend Enlistment (NAVPERS 1070/621)
Certificate of Release or Discharge from Active Duty (DD Form 214)
General Purpose Privacy Act Statement (OPNAV 5211/12)
FILE MUST BE REVIEWED ANNUALLY
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
__________________________________________________
Reviewed By
Date
NSTC 1533/128 (Rev. 07-11)
FOR OFFICIAL USE ONLY
Our nation’s Naval service, made up of the Navy and Marine Corps, has successfully met every
challenge. Between 13 October and 10 November 1775, the Continental Congress authorized a few
Honor:
"I will bear
true
faithbattalions
and allegiance
…“ and I will
myself
in the
highest
ethical
manner
in all
small warships
and
a two
of Marines.
Justconduct
after New
Year’s
Day
in 1776,
five
companies
that
I do. I will
abide by an
uncompromising
of integrity,
full responsibility
for my actionsand
and set
of Marines
embarked
aboard
these new code
warships
of the taking
Continental
Navy in Philadelphia
my
word.
I
am
accountable
for
my
behavior,
both
professional
and
personal,
and
remain
ever
mindful
sail. Eight weeks later and only 5 months after authorization by the Congress, 230 Marines of
& 50
the privilege of service to my fellow Americans.
Sailors assaulted across the beach in the Bahamas to capture gunpowder and weapons from a British
fort. US Sailors & Marines had landed for the first time in history and the situation was well in
Courage: "I will support and defend ...“ and I will demonstrate the courage to meet the demands of naval
hand. From
thoseisearly
days
of naval
expeditionary
service,
our bedrock
principles
service;
to do what
right at
all times,
especially
in the face
of temptation
or adversity.
I willhave
makeremained
constant.inOur
core
values
of nation
honor,
courage,
commitment
remainI will
theadhere
distinguishing
decisions
the best
interest
of the
without
regardand
for personal
consequence.
to the
characteristics
of
the
Naval
Service.
highest standard of personal conduct and decency. My moral courage will give me the strength to always
do what is right.
Honor: "I will bear true faith and allegiance …“ I will conduct myself in the highest ethical
Commitment:
and faithfully
I will demonstratecode
respect
and downtaking
the chain
manner in all"I will
thatwell
I do.
I will discharge
abide by...“anand
uncompromising
of upintegrity,
full
command
while
caring
for
Honor:
"I
will
bear
true
faith
and
allegiance
…“
and
I
will
conduct
myself
in
the
responsibility for my actions and my word. I am accountable for my behavior, both professional
highest
ethical and
manner
in allever
that mindful
I do. I willofabide
by an uncompromising
code
integrity,
taking full
and personal,
remain
the privilege
I have to serve
myoffellow
Americans.
responsibility for my actions and my word. I am accountable for my behavior, both professional and
personal, and remain ever mindful of the privilege of service to my fellow Americans.
Courage: "I will support and defend ...“ I will demonstrate the courage to meet the demands of
naval service; to do what is right at all times, especially in the face of temptation or adversity. I will
Courage: "I will support and defend ...“ and I will demonstrate the courage to meet the demands of naval
make decisions
inisthe
interest
of the nation
regard fororpersonal
consequence.
service;
to do what
rightbest
at all
times, especially
in thewithout
face of temptation
adversity.
I will make I will
adhere
to
the
highest
standard
of
personal
conduct
and
decency.
My
moral
courage
give
decisions in the best interest of the nation without regard for personal consequence. I will will
adhere
to me
the the
strengthstandard
to always
do what conduct
is right.and decency. My moral courage will give me the strength to always
highest
of personal
do what is right.
Commitment: "I will well and faithfully discharge ...“ I will demonstrate respect up and down the
Commitment:
"I will well
andcaring
faithfully
...“ and Iand
will demonstrate
respect up
thepeople.
chain
chain of command
while
for discharge
the professional
personal well-being
ofand
eachdown
of our
of
command
while caring
forhuman
the professional
andrespect.
personal Iwell-being
I will treat
I will
treat everyone
with
dignity and
will workofaseach
partofofour
thepeople.
Navy-Marine
Corps
everyone
with
human
dignity
and
respect.
I
will
work
as
part
of
the
Navy-Marine
Corps
Team
to
accomplish
Team to accomplish each mission assigned and to insure the future of our nation.
every mission assigned and to insure the future of our great nation.
A midshipman is a person of integrity and stands for that which is right. I tell the truth and
the professional and personal well-being of each of our people. I will treat everyone with human dignity
ensure
that the full truth is known, I do not lie. I embrace fairness in all actions. I ensure that
and respect. I will work as part of the Navy-Marine Corps Team to accomplish every mission assigned and to
work
submitted
asour
mygreat
own nation.
is my own, and that assistance received from any source is authorized
insure the future of
and properly documented. I do not cheat. I respect the property of others and ensure that others
are able to benefit from the use of their own property. I do not steal.”
I have read and understand the NROTC Concept of Honor effective this date ____________.
Signature of Midshipman
NSTC 1533/121
Signature of witness
NAVAL RESERVE OFFICERS TRAINING CORPS
COLLEGE PROGRAM APPLICATION
Privacy Act Statement
Authority: The authority to request this information is contained in: 5 USC § 301 (Authorizing Forms and Regulations); Executive Order 9397 (Use of
Social Security Numbers).
Principal Purpose(s): To be completed by applicants for the Naval Reserve Officers Training Corps (NROTC) College Program.
Routine Use(s): Information you provide in this application is protected by the Privacy Act and will not be released outside the Department of
Defense without your permission unless it comes within an exception to the Act or one of the routine uses in 32 CFR § 701.112,
http://www.privacy.navy.mil and the routine uses set forth here.
Disclosure: You are not required to provide this information; however, failure to do so will result in an inability to fairly evaluate your application and
may result in an inability to process the application.
Personal Information
SSN (last 4)
Name
Phone Number
Cell Phone Number
Date of Birth
Place of Birth
Current Mailing Address
Name of Parent/Guardian
Address of Parent/Guardian
Are you a US Citizen?
Yes
USN
No
USMC
If Naturalized, give date, place, court of jurisdiction, and certificate number:
Military Experience and Training (Past and Present, if any)
Service
Dates of Service
Training Programs
JROTC
(Service _________)
Highest Rank
Position(s) Held
Type of Discharge
EAOS
Awards
Grades of Participation
9
10
11
12
Civil Air Patrol
9
10
11
12
Other (NDCC, etc.)
9
10
11
12
Extracurricular Activities
READ CAREFULLY: Identify only those activities in which you engaged during school grades 9-12. NROTC is particularly interested in identifying
activities in which an applicant has participated involving responsibility and leadership.
Organization
Position(s) Held
Grades of Participation
Hrs/ Wk
9
10
11
12
9
10
11
12
9
10
11
12
9
10
11
12
Athletic Activities
READ CAREFULLY: Identify only those sports which you participated in during school grades 9-12. Mark the year in which you received a letter and/or
you were on varsity. Mark the box if you participated in JV or on a club team during any year. Do not list intramural activity.
Sport
Position(s) Held
Awards/Recognition
Letter
Varsity
JV/Club
9
10
11
12
9
10
11
12
9
10
11
12
9
10
11
12
9
10
11
12
9
10
11
12
Other Activities
Attach additional sheets, if needed, to identify other activities not listed above that involve considerable responsibility and leadership. List positions
held and the average number of hours devoted per week to the activity.
NSTC 1533/133 (10-11)
Page 1 of 2
Employment
List in chronological order beginning with the most recent, each period of full-time, part-time, or self-employment. List inclusive dates for each period.
If discharged for cause from any employment, so state. Include any leadership responsibilities.
Dates
From
To
Employer Name and Address
Hrs/Wk
Type of Work Performed
Education
List in chronological order beginning with the most recent school attended. Include any/all college work, whether or not a degree was earned. Attach
transcripts.
Dates
School Name and Address
Major
Degree
From
To
Academics
PSAT
Verbal: __________
Math: __________
High School Name: ___________________________________
SAT
Verbal: __________
Math: __________
Class Rank: __________
Class Size: __________
ACT
Verbal: __________
Math: __________
GPA: __________
GPA Scale: __________
Answer the following questions. If you answer YES, provide explanations on an additional sheet.
1. Have you ever applied for or signed any agreement concerning any program leading to a commission in any of
the Armed Forces of the United States? (If you answer YES, list the date, place of application, program
applied for and current status of application.)
Yes
No
2. Have you signed an Enlistment Contract (DD Form 4) with any of the Armed Forces of the United States? (If
you answer YES, list the date, place, service and current status of enlistment.)
3. Have you ever been arrested, detained, indited, summoned into court, or convicted for any violation of civil or
military law, including juvenile offenses and moving traffic violations? (If you answer YES, give complete
description of incident, name and place of court, nature of offense, date and disposition of case.)
4. Are you currently awaiting trial or sentence, on probation, under suspended sentence or under any other type
of military or civilian restraint as a result of violation of law or regulation?
5. Have you ever been known by any other name or names other than that used in this application? (If you
answer YES, even if such differences were only differences in spelling, explain in affidavit form and submit
with application.)
6. Do you have any moral obligations or personal convictions that will prevent you from conscientiously bearing
arms and supporting and defending the Constitution of the United States against all enemies, foreign and
domestic?
7. Have you ever taken any narcotic, sedative, or tranquilizer drugs other than as prescribed by a physician or
dentist? (If you answer YES, attach a statement with the full circumstances, number of times used, amounts
taken, period over which taken, and intent for further use.)
8. Have you ever been arrested or convicted of trafficking illegal drugs?
9. Have you ever used LSD, marijuana, sniffed glue or used any other hallucinogens, hypnotic, stimulants, or
other known harmful or habit-forming drugs and/or chemicals? (If you answer YES, attach a statement with
the full circumstances, number of times used, amounts taken, period over which taken, and intent for further
use.)
I certify that all information given by me is complete and correct to the best of my knowledge.
I understand that this applicant questionnaire does not obligate me in any way, and that I may withdraw my application at any time.
Signature
Date
NROTC COLLEGE PROGRAM OATH
“I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will
bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well
and faithfully discharge the duties of office on whicch I am about to enter: So help me God."
Signature
Date
NSTC 1533/133 (10-11)
Page 2 of 2
NAVAL RESERVE OFFICERS TRAINING CORPS DRUG AND ALCOHOL
STATEMENT OF UNDERSTANDING
Authority: 5 U.S.C. 301 (Authorizing Forms and Regulations); 10 U.S.C. 2103 (Eligibility for Membership), 2104 (Eligibility for Advanced Training),
2107 (Senior ROTC Financial Assistance Program), 2122 (Eligibility for Health Professions Scholarship and Financial Assistance Program);
Executive Order 9397 (Use of Social Security Numbers); OPNAVINST 5350.4D (Navy Alcohol and Drug Abuse Prevention and Control); and NSTC
M-1533.2 at 2-27 and 2-28.
Principal Purposes: To obtain information used to evaluate an individual’s compliance with policy and fitness for service as a commissioned officer.
Routine Uses: Those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act and the routine uses set forth in 32 C.F.R. 701.112.
Disclosure: Disclosure is voluntary. However, failure to provide the requested information may result in adverse administrative action and/or
ineligibility for, or disenrollment from, the NROTC Program.
STATEMENT OF UNDERSTANDING
I,
FIRST MIDDLE LAST
understand the following:
(Full name – first, middle, last)
1. Participation in the Naval Reserve Officer Training Corps (NROTC) places me in a position of special trust and responsibility.
2. As established by OPNAVINST 5350.4D, the abuse of drugs or alcohol violates this position of special trust and endangers my health and safety
as well as the safety of others.
3. In accordance with OPNAVINST 5350.4D, Naval Service Training Command (NSTC) maintains a “zero tolerance” policy regarding drug abuse.
Additionally, all misconduct resulting from the misuse of alcohol will be dealt with immediately and effectively.
4. As a student participating or enrolled in the NROTC Program as a NROTC Midshipman (MIDN), NROTC College Program Student (Basic or
Advanced), or Strategic Sealift Officer Program, I understand and agree to be bound by NSTC’s policy regarding drug and alcohol abuse as reflected
in the Regulations for Officer Development, NSTC M-1533.2. Additionally, I understand I will be screened by urinalysis within 30 days of first
reporting for training to the NROTC unit to which I have been assigned and may be subject to random urinalysis screening as directed by NSTC.
5. By signing the certification below, I acknowledge that a single detection of drug abuse or incident of alcohol abuse after entry into any program
listed within paragraph 4 may result in my disenrollment or removal from that program, and, if on scholarship, either the recoupment of all scholarship
monies I have received or Active Enlisted Service as may be directed by the Secretary of the Navy.
CERTIFICATION
I have read and fully understand all the information contained on this form.
Typed/Printed Name (last, first, middle)
Signature:
Date:
CERTIFYING OFFICIAL AND WITNESS
I certify the above individual signed this certificate in my presence.
Typed/Printed Name and Title of Official Certifying
J. Burkette, CDR USN, XO
Signature:
Date:
Typed/Printed Name and Title of Witness
Signature:
NSTC 1533/153 (Rev. 11-13)
Date:
Page 1 of 1
PRIVACY ACT STATEMENT - HEALTH CARE RECORDS
This form is not an authorization or consent to use or disclose your health information.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN):
10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. Chapter 55, Medical and Dental Care;
42 U.S.C. Chapter 32, Third Party Liability for Hospital and Medical Care; 32 CFR Part 199, Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS); DoDI 6055.05, Occupational and Environmental Health (OEH); and
E.O. 9397 (SSN), as amended.
2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED:
Information may be collected from you to provide and document your medical care; determine your eligibility for benefits
and entitlements; adjudicate claims; determine whether a third party is responsible for the cost of Military Health System
(MHS) provided healthcare and recover that cost; evaluate your fitness for duty and medical concerns which may have
resulted from an occupational or environmental hazard; evaluate the MHS and its programs; and perform administrative tasks
related to MHS operations and personnel readiness.
3. ROUTINE USES:
Information in your records may be disclosed to:
Private physicians and Federal agencies, including the Department of Veterans Affairs, Health and Human Services, and
Homeland Security (with regard to members of the Coast Guard), in connection with your medical care;
Government agencies to determine your eligibility for benefits and entitlements;
Government and nongovernment third parties to recover the cost of MHS provided care;
Public health authorities to document and review occupational and environmental exposure data; and
Government and nongovernment organizations to perform DoD-approved research.
Information in your records may be used for other lawful reasons which may include teaching, compiling statistical data, and
evaluating the care rendered. Use and disclosure of your records outside of DoD may also occur in accordance with 5 U.S.C.
552a(b) of the Privacy Act of 1974, as amended, which incorporates the DoD Blanket Routine Uses published at:
http://dpcld.defense.gov/privacy/SORNsIndex/BlanketRoutineUses.aspx.
Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA
Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD by DoD 6025.18-R. Permitted uses and disclosures of
PHI include, but are not limited to, treatment, payment, and healthcare operations.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING
INFORMATION:
Voluntary. If you choose not to provide the requested information, comprehensive health care services may not be possible,
you may experience administrative delays, and you may be rejected for service or an assignment. However, care will not be
denied.
This all inclusive Privacy Act Statement will apply to all requests for personal information made by MHS health care treatment
personnel or for medical/dental treatment purposes and is intended to become a permanent part of your health care record.
Your signature merely acknowledges that you have been advised of the foregoing. If requested, a copy of this form will be
furnished to you.
5. SIGNATURE OF PATIENT OR SPONSOR
DD FORM 2005, JUN 2016
6. SOCIAL SECURITY NUMBER OR
DOD IDENTIFICATION NUMBER
OF MEMBER OR SPONSOR
PREVIOUS EDITION IS OBSOLETE.
7. DATE (YYYYMMDD)
Adobe Designer 9.0
GENERAL PURPOSE PRIVACY ACT STATEMENT
PART A ·IDENTIFICATION OF REQUIREMENT
1. REQUIRING DOCUMENT (Describe- SECNAVINST, OPNAVNOTE,SECNAV ltr, etc.)
2. SPONSOR CODE
OPNAV 5211/12
None
3. DESCRIPTIVE TITLE OR REQUIREMENT (Form title, report title, etc.)
NROTC Student File and associated documents
PART B ·INFORMATION TO BE FURNISHED TO INDIVIDUAL
1.
AUTHORITY
5U.S.C. 562a (Privacy Act of 1974)
5U.S.C. 552 (Freedom of Information Act)
2. PRINCIPLE PURPOSE(S)
The NROTC Student File is maintained by the parent Naval Reserve Officer Training Corps Unit and is used to document a person's
performance while enrolled as a member of the NROTC Program.
3. ROUTINE USE(S)
The NROTC Student File is used routinely to document a person's perfo1mance while enrolled as a member of the NROTC Program.
4. MANDATORY OR VOLUNTARY DISCLOSURE AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION
Disclosure of information is voluntary but failure to provide requested information could result in failure to obtain permission to
enroll in the NROTC Program or disenrollment from the NROTC Program.
PART C ·IDENTIFICATION OF FORM/REPORT/OTHER REQUIREMENT
1. FORMNO./REPORT CONTROL SYMBOU OTHER IDENTIFICATION
None
OPNAV 5211/12 (MAR 1992)
PRIVACY ACT STATEMENT
(Student ID#)
NROTC Student Records
Standard Form 1199A (EG)
OMB No. 1510-0007
(Rev. June 1987)
Prescribed by Treasury
Department
Treasury Dept. Cir. 1076
DIRECT DEPOSIT SIGN-UP FORM
DIRECTIONS
The claim number and type of payment are printed on Government
To sign up for Direct Deposit, the payee is to read the back of this form
checks. (See the sample check on the back of this form.) This
and fill in the information requested in Sections 1 and 2. Then take or
information is also stated on beneficiary/annuitant award letters and
mail this form to the financial institution. The financial institution will
other documents from the Government agency.
verify the information in Sections 1 and 2, and will complete Section 3.
The completed form will be returned to the Government agency
Payees must keep the Government agency informed of any address
identified below.
changes in order to receive important information about benefits and to
remain qualified for payments.
A separate form must be completed for each type of payment to be
sent by Direct Deposit.
SECTION 1 (TO BE COMPLETED BY PAYEE)
A NAME OF PAYEE (last, first, middle initial)
D TYPE OF DEPOSITOR ACCOUNT
CHECKING
SAVINGS
E DEPOSITOR ACCOUNT NUMBER
ADDRESS (street, route, P.O. Box, APO/FPO)
CITY
B
STATE
ZIP CODE
F TYPE OF PAYMENT (Check only one)
Social Security
Supplemental Security Income
Railroad Retirement
Civil Service Retirement (OPM)
VA Compensation or Pension
TELEPHONE NUMBER
AREA CODE
NAME OF PERSON(S) ENTITLED TO PAYMENT
C CLAIM OR PAYROLL ID NUMBER
Fed. Salary/Mil. Civilian Pay
Mil. Active
Mil. Retire.
Mil. Survivor
Other
(specify)
G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable)
TYPE
Prefix
AMOUNT
Suffix
PAYEE/JOINT PAYEE CERTIFICATION
JOINT ACCOUNT HOLDERS’ CERTIFICATION (optional)
I certify that I am entitled to the payment identified above, and that I have
read and understood the back of this form. In signing this form, I
authorize my payment to be sent to the financial institution named below
to be deposited to the designated account.
I certify that I have read and understood the back of this form,
including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS.
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
DATE
SECTION 2 (TO BE COMPLETED BY PAYEE OR FINANCIAL INSTITUTION)
GOVERNMENT AGENCY NAME
GOVERNMENT AGENCY ADDRESS
SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION)
NAME AND ADDRESS OF FINANCIAL INSTITUTION
CHECK
DIGIT
ROUTING NUMBER
DEPOSITOR ACCOUNT TITLE
FINANCIAL INSTITUTION CERTIFICATION
I confirm the identity of the above-named payee(s) and the account number and title. As representative of the above-named financial institution, I
certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209, and
210.
PRINT OR TYPE REPRESENTATIVE’S NAME
SIGNATURE OF REPRESENTATIVE
TELEPHONE NUMBER
DATE
Financial institutions should refer to the GREEN BOOK for further instructions.
THE FINANCIAL INSTITUTION SHOULD MAIL THE COMPLETED FORM TO THE GOVERNMENT AGENCY IDENTIFIED ABOVE.
NSN 7540-01-058-0224
GOVERNMENT AGENCY COPY
Reset
1199-207
Designed using Perform Pro, WHS/DIOR, Mar 97
SF 1199A (Back)
BURDEN ESTIMATE STATEMENT
The estimated average burden associated with this collection of information is 10 minutes per respondent or recordkeeper, depending on
individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be
directed to the Financial Management Service, Records Management Branch, Room 135, 3700 East-West Highway, Hyattsville, MD 20782.
THIS ADDRESS SHOULD ONLY BE USED FOR COMMENTS AND/OR SUGGESTIONS CONCERNING THE AMOUNT OF TIME SPENT TO
COLLECT THIS DATA. DO NOT SEND THE COMPLETED PAPERWORK TO THE ADDRESS ABOVE FOR PROCESSING.
PRIVACY ACT NOTICE
Collection of the information in this Direct Deposit Sign-Up form is authorized by 5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397
(November 22, 1943). Your social security number and the other information requested will allow the federal government to process your direct
deposit. Your social security number is requested to ensure the accurate identification and retention of records pertaining to you and to distinguish you
from other recipients of federal payments. This information will be disclosed to the Department of the Treasury and its fiscal and financial agents, and
other federal agencies, as necessary to process your direct deposit. This information may also be disclosed to a court, congressional committee or
another government agency as authorized or required to verify your receipt of federal payments. Although providing the requested information is
voluntary, your direct deposit cannot be processed without it.
PLEASE READ THIS CAREFULLY
All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 209 and/or 210. The information is
confidential and is needed to prove entitlement to payments. The information will be used to process payment data from the Federal agency to
the financial institution and/or its agent. Failure to provide the requested information may affect the processing of this form and may delay or
prevent the receipt of payments through the Direct Deposit/Electronic Funds Transfer Program.
INFORMATION FOUND ON CHECKS
Most of the information needed to complete boxes A and F in
Section 1 is printed on your government check:
United States Treasury
Month Day Year
08
31
84
15-51
000
KANSAS CITY, MO
28
A Be sure that payee’s name is written exactly as it
appears on the check. Be sure current address is shown.
F Type of payment is printed to the left of the amount.
Pay to
the order of
Check No.
0000 415785
28
VA COMP
JOHN DOE
123 BRISTOL STREET
HAWKINS BRANCH TX 76543
A
DOLLARS
CTS
$****100
00
F
NOT NEGOTIABLE
’:00000518’: 041571926"
SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS
Joint account holders should immediately advise both the Government agency and the financial institution of the death of a beneficiary. Funds
deposited after the date of death or ineligibility, except for salary payments, are to be returned to the Government agency. The Government agency
will then make a determination regarding survivor rights, calculate survivor benefit payments, if any, and begin payments.
CANCELLATION
The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the Federal agency or by the death
or legal incapacity of the recipient. Upon cancellation by the recipient, the recipient should notify the receiving financial institution that he/she is doing so.
The agreement represented by this authorization may be cancelled by the financial institution by providing the recipient a written notice 30 days in
advance of the cancellation date. The recipient must immediately advise the Federal agency if the authorization is cancelled by the financial institution.
The financial institution cannot cancel the authorization by advice to the Government agency.
CHANGING RECEIVING FINANCIAL INSTITUTIONS
The payee’s Direct Deposit will continue to be received by the selected financial institution until the Government agency is notified by the payee that
the payee wishes to change the financial institution receiving the Direct Deposit. To effect this change, the payee will complete a new SF 1199A at the
newly selected financial institution. It is recommended that the payee maintain accounts at both financial institutions until the transition is complete, i.e.
after the new financial institution receives the payee’s Direct Deposit payment.
FALSE STATEMENTS OR FRAUDULENT CLAIMS
Federal law provides a fine of not more than $10,000 or imprisonment for not more than five (5) years or both for presenting a false statement or
making a fraudulent claim.
ADMINISTRATIVE REMARKS
NAPERS 10/70/613 (REV 10-81)
S/N 0106-LF-010-6991
SHIP OR STATION:
COMMANDING OFFICER, NROTC UNIT VIRGINIA TECH, BLACKSBURG VA 24061-0241
COMMUTATION IN LIEU OF UNIFORMS FOR ENROLLED MEMBERS OF NROTC
It is Department of Defense Policy that standard uniform commutation rates for the
basic NROTC course (first two years) and the advanced course (third and fourth years)
shall be paid by the government after cadets have been enrolled in the NROTC Program
under the following criteria:
New NROTC enrollees: the first semester after taking the Scholarship or College
Program oath shall qualify as an initial probationary period.
All other students: must remain in good standing with the NROTC Unit through the first
day of the second semester to receive payment for that year.
Students disenrolled from the NROTC Program Prior to the above guidelines will not be
eligible for the uniform commutation allowance, and the student will be responsible for
payment.
I, ________________________, understand that if I disenroll from the program during the
probationary period as explained above, I will not be eligible for the uniform commutation fund
and will be liable to pay uniform charges to the university.
______________________
Witness
NAME (Last, First, Middle)
___________________________
Signature
SSN
____________
Date
BRANCH AND CLASS
NROTC/USN
UNITED STATES NAVY TATTOO SCREENING CERTIFICATE
COMNAVCRUITCOMINST 1130.8 and 1131.2
NAME (Last, First, Middle, Jr., etc.)
Date:
YES
NO
N/A
1. Does the applicant/candidate have any tattoos/body art/branding?
2. Does the applicant/candidate have any tattoo/body art/brand visible behind the ears or on the neck
3. Has the applicant/candidate ever had any tattoo, body art or brand removed or covered?
Any "Yes" response above requires an enlistment eligibility determination by the NAVCRUITDIST CO (May be delegated to XO, ROPS, CMC, CR, or EPDS when authorized "by direction" authority by the CO).
YES
NO
N/A
4. Are any of the tattoos/body art/brands on the face (excluding cosmetic tattoos) or scalp?
5. Is there one or more tattoos larger than one inch on the neck or behind the ears, visible above the collar of a
properly fitted crew neck t-shirt? (Excluding cosmetic tattoos)
6. If applicable, are cosmetic tattoos applied in good taste with natural color enhancement and of a
conservative nature?
7. Are any of the tattoos/body art/branding representative of gang membership, advocate racial, ethnic,
racial discrimination, sexism (including expressions of nudity), drug related, obscene, or are prejudicial to
good order, discipline, and morale, or are of a nature to bring discredit upon the Navy?
8. Are any of the tattoos a result of a specific activity? (i.e., specifically an illegal activity or as a result of any
violation of law (s))
Any "Yes" response to items 4, 5, 7, or 8 above is disqualifying, not authorized for Enlistment. Any "No" response to
Item 6 is disqualifying, not authorized for Enlistment.
NOTE: All questionable body markings, due to content, size, number, and/or location, shall be forwarded to NAVCRUITCOM for eligibility
determination.
Applicant Signature
Date
Recruiter Signature
Date
Describe all tattoos, brands, and/or body ornamentation (if applicable) on following page.
Explain tattoo, brand, and/or body ornamentation removal process, if applicable.
CO/XO/R-OPS/CMC/CR/EPDS Reviewing Comments:
APPROVED
DISAPPROVED
CO/XO/R-OPS/CMC/CR/EPDS Signature
NAVCRUIT 1130/104
(Rev 05-2016)
Typed Name/Title:
For Official Use Only - Privacy Sensitive
Date:
Page 1 0f 2
UNITED STATES NAVY TATTOO SCREENING CERTIFICATE
Documentation.
The following depicts the location and description of the applicant's
body markings.
Place number on body location and describe in corresponding blocks below
indicating content and size in inches (not required if no Tattoos):
FRONT VIEW
BACK VIEW
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
Part V. Certification.
10.
I certify above body marking information is accurate.
(Name of Applicant)
(Signature of Applicant)
(Name of Recruiting Rep)
(Signature of Recruiting Rep)
NAVCRUIT 1130/104 (Rev 05/2016)
(Date)
(Date)
Page 2 of 2
OPMIS FORM
PLEASE COMPLETE THE FOLLOWING:
1. Social Security Number:
2. Last Name:
3. First Name:
4. Middle Initial:
5. Class Year: FRESHMAN
Freshman
6. Option Code: A one character code that denotes whether a student is Navy or Marine option.
N= Navy
M= Marine
O = Other (Placement, NSI)
7. Program Code:
5A
A two character code indicating the specific scholarship or college program contract a student has
established with the Navy. These codes may be entered by the unit only on an initial enrollment of a student
into the ADS. Any changes will be entered by CNET only. Broken down into two separate parts:
First Part
1 = PNS Engineering Scholarship
2 = PNS Minority Scholarship
4 = National Competition Scholarship
5 = College Program
6 = CNET Controlled Scholarship (PNS Nominee)
7 = Restricted Line Nurse Program
Second Part
A. = Four Year
B. = Three Year
C. = Two year
D. = One Year
E. = ECP student
F. = Financial hardship (KCP only)
G. = CEC – ECP
N. = Nuclear Student (Eep only)
S. = Pre-selected Three Year Scholarship (First digit must be a "S")
Placement - All four year scholarship recipients will have "4A" entered automatically.
ECP - Uses codes SE, 5F, 5G and 5N.
NSI - uses 5C and 4C.
9. Date of Birth:
10. Sex:
11. Race:
A = American Indian or Alaska Native
B = Asian
C = Black or African American
D = Native Hawaiian or other Pacific Islander
E = White
12. Ethnic:
A student’s ethnic group (segments of the population that possess common characteristics significantly
different from that of the general population). This entry is for all students.
1 =Other Hispanic Descent (Includes all personnel of Spanish extraction, except when delineated separately)
2 = U.S./Canadian Indian Tribes (Persons belonging to U.S. or Canadian Indian Tribes other than Aleut or
Eskimo)
3 = Other Asian Descent (Persons of Asian descent not delineated separately as Chinese, Japanese, Korean,
Indian, Filipino, or Vietnamese)
4 = Puerto Rican (Persons of Puerto Rican descent)
5 = Filipino (Persons from the Philippine Islands and their descendants)
6 = Mexican (Includes Chicano)
7 = Eskimo (Does not include Aleuts)
8 = Aleut (Persons of Aleut descent)
9 = Cuban (Persons of Cuban descent)
D = Indian (Persons from India and their descendants)
E = Melanesian (Melanesian descent)
G = Chinese (Persons of Chinese descent)
J = Japanese (Persons of Japanese descent)
K = Korean (Persons of Korean descent)
L = Polynesian (Persons of Polynesian descent)
Q = Other Pacific Island descent (Pacific Islands and their descendants not delineated separately)
S = Latin American with Hispanic descent (Persons from Central and South America and descendants who
lave Spanish heritage)
V = Vietnamese (Persons of Vietnamese origin and their descendants)
W = Micronesians (Persons of Micronesian descent)
X = Other (A member of an ethnic group not included above)
Y = None (Not Associated with any particular ethnic group)
Z = Unknown (Self-explanatory)
13. Physical Status
14. Waiver granted (if applicable)
15. Home State:
16. Resident Code:
A one character field indicating the residential status of a student with a respect to the college he/she is
attending.
N = Nonresident
R = Resident
P = Private School
17. Date Enrolled:
18. Date of Scholarship:
19. Date Committed
20. End of Obligated Service:
21. Estimated Date of Commissioning:
22. Active Duty Status (If applicable)
23. Previous Military Service:
A one character field indicating the branch of military service in which a student served on active duty prior
to commissioning in the U.S. Navy or U.S. Naval Reserve.
A = Active Army commissioned service
B = Active Air Force commissioned service
C = Active Coast Guard commissioned service
D = Active Marine Corps commissioned service
E = Active National Guard commissioned service
F = Active Fore an commissioned service
G = Other active commissioned service
N = Active Navy enlisted service
P = Active Army enlisted service
Q = Active Air Force enlisted service
R = Active Coast Guard enlisted service
S = Active Marine Corps enlisted service
T = Active National Guard enlisted service
U = Active foreign enlisted service
V = Other active enlisted service
24. Source Code:
A one character field identifying the organized military or academic program a student
was enrolled in prior to entry into the NROTC program.
I = NSI
J = NJROTC
T = BOOST
V= ACDU Navy
C = ACDU Marine Corps
O = Other
MECEP - T = BOOST
“ ” = all others
25. History:
Eight one digit fields to indicate special program tracking as indicated.
Block 1 "Type JROTC"
Blank = No JROTC
F = Air Force
A = Army
N = Navy
M= Marine
Block 2 "Marital Status"
M = Married
D = Divorced
S = Single
Block 3 "Number of Dependents" (for whom you are responsible)
0=0
1 = 1 through 9 = 9
Block 4 "Percentile High School Rank"
0 = Not Applicable (GED)
1 = Top 20%
2 =Top 40%
3 = Top 60%
4 = Top 80%
5 = below top 80%
Block 5 “Eagle Scout”
Y = Yes
N =No
Block 6 “Military” (Child of Career Military Member)
Y = Yes
N =No
Block 7 "High School Type"
0 = Not applicable (GED)
1 =Public (Graduating class greater than 100)
2 = Public (Graduating class less than 100)
3 =Private School (Graduating class greater than 100)
4 =Private School (Graduating class less than 100)
Block 8 "Demographic Type"
1 = Urban (City greater than 500,000)
2 =Suburban (Clty less than 500,000)
3 =Rural, farming/country environment
26. ACT or SAT Scores (Composite, Math, Verb)