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CADET ENROLLMENT RECORD
For use of this form, see [NAME] 145-4, the proponent agency is ATCC-PC
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Authority |  |  |  |  | 10 USC 2101, 2103, 2104, 2107, 2111, and 5 USC 301
Principal Purpose(s) |  |  |  |  | To obtain personnel data in order to determine eligibility for enrollment and serve as a source document for cadet's service record throughout participation in the ROTC Program. Provides data for the
 |  |  |  |  | administration of the [NAME] student commencing with application for enrollment into the ROTC Program.
Routine Uses |  |  |  |  | To verify eligibility to participate in the ROTC Program; to provide information on addresses and telephone numbers for use in the event of death, injury, illness or unauthorized absence while
 |  |  |  |  | participating in [NAME] activities; to facilitate contact with complete information with a cadet during other than normal training periods; to make a matter of record the information provided by the cadet.
Disclosure |  |  |  |  | Disclosure is voluntary. However, failure to provide complete information and provide responses will suspend the enrollment process into the ROTC Program.
PART I - GENERAL INFORMATION
1.  NAME |  |  |  |  |  |  |  |  |  |  |  |  | 2.  SSN |  |  |  |  | 3.  COLLEGE ID # |  |  |  |  |  | 4.  [NAME]
5.  LOCAL ADDRESS |  |  |  |  |  |  |  |  |  |  |  |  | 5a.  CITY |  |  |  |  |  |  | 5b.  STATE |  |  | 5c. ZIP CODE |  |  |  |  |  | 6. PHONE NUM
7.  PERMANENT ADDRESS |  |  |  |  |  |  |  |  |  |  |  |  | 7a.  CITY |  |  |  |  |  |  | 7b.  STATE |  |  |  |  | 7c. ZIP CODE |  |  |  |  |  | 8. PH NUM
9.  DOB |  |  |  | 10.  POB |  |  |  |  |  |  |  |  |  |  |  |  | 11.  RELIGIOUS PREF |  |  |  |  |  |  |  | 12. BLOOD TYPE |  |  |  | 13. ACT |  |  | 14.  SAT
15.  SEX |  |  | 16. HEIGHT |  |  |  | 17. WEIGHT |  |  |  |  |  | 18. [NAME] |  |  |  |  |  |  | 19.  DEPENDENTS |  |  |  |  |  | 19a.  NUMBER OF DEPENDENTS
20.  RACE/ETHNICITY (Check One) |  |  |  |  |  |  | African American |  |  |  |  | American Indian |  |  |  |  | Asian |  |  | Caucasian |  |  |  | Hispanic |  |  |  | Other
21.  [NAME] (Check One) |  |  |  |  |  |  | U.S. Citizen: |  |  |  | U.S. Born |  |  |  | Naturalized |  |  |  | Born Overseas With U.S. Parents |  |  |  |  |  |  |  | Dual Citizenship (See CC PAM 145-4, 2-39)
 |  |  |  |  |  |  | Non U.S. Citizen: |  |  |  |  | Immigrant Alien |  |  |  |  | Nonimmigrant Alien |  |  |  |  |  | Refugee
22.  Do you have any condition that could interfere with you participating in a normal college physical education course? |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 22a.  If "yes" explain
23.  Have you ever received Medical Disability payments from any source? |  |  |  |  |  |  |  |  |  |  |  |  | 23a. If "yes" explain
24.  NEXT OF KIN |  |  |  |  |  |  |  |  |  |  |  |  | 24a.  ADDRESS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 24b. PHONE NO
PART II - ACADEMIC INFORMATION
25.  [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 25a.  FICE CODE |  |  |  |  | 26.  SCHOOL OF ATTENDANCE |  |  |  |  |  |  |  |  |  |  |  |  |  | 26a.  FICE CODE
27.  RESIDENCY STATUS |  |  |  |  |  | 28. ACADEMIC CLASS |  |  |  |  |  | 29. PROJECTED GRADUATION DATE |  |  |  |  |  |  |  |  |  | 30.  ACADEMIC MAJOR
31. [NAME] |  |  |  |  |  |  |  |  |  |  |  | 32. CREDITS TOWARD DEGREE |  |  |  |  |  |  |  | 33. CREDITS REQUIRED FOR DEGREE |  |  |  |  |  |  |  |  | 34. CGPA (COLLEGE)
35.  OTHER COLLEGES ATTENDED |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 35a. [NAME]) ATTENDED |  |  |  |  |  | 36. HIGH SCHOOL ATTENDED
36a.  GRADUATION DATE |  |  |  |  |  |  | 37. [NAME] |  |  |  |  |  |  |  |  |  |  |  | 37a.  If "yes" what type?
38.  OTHER SCHOLARSHIPS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 39. JROTC EXPERIENCE
PART III - CURRENT OR PRIOR MILITARY SERVICE (TO INCLUDE OFFICER PRODUCING PROGRAMS)
 |  | NOT APPLICABLE (Go to PART IV) |  |  |  |  |  |  | 40. CURRENT SERVICE: |  |  |  |  | Are you currently in the Armed Forces? |  |  |  |  |  |  |  | 40a.  If "yes" which Branch?
40b. SMP UNIT |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 40c.  Is your spouse currently a member of the Armed Forces?
41. PRIOR SERVICE: |  |  |  | Have you ever been enrolled in an officer producing program? |  |  |  |  |  |  |  |  |  |  | 41a. Were you ever disenrolled from the ROTC Program?
41b.  Were you ever enrolled in a Service Academy? |  |  |  |  |  |  |  |  |  | 41c. Were you ever discharged from the Armed Forces? |  |  |  |  |  |  |  |  |  | 41d. If "yes" what type of discharge? |  |  |  |  |  |  |  | 41e. If "yes" what was the RE Code?
41f.  Months of Active Service |  |  |  |  |  | 41g. Have you ever been discharged for medical reasons? |  |  |  |  |  |  |  |  |  |  | 41 h.  If "yes", explain:
CC Form 139-R, DEC 07 |  |  |  |  |  |  |  |  | REPLACES ALL PREVIOUS EDITIONS, WHICH ARE OBSOLETE. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 1 of 6