APPLICATION FOR ACTIVE DUTY SERVICE MEMBERS
1. Applicant’s full name: ___________________________________________________________
Student ID#/Social Security Number: _______________________ Rank: ________________
Date of Birth: _____/_____/________
2. Check one of the following armed services in which you are currently serving on active duty:
□ US Marine Corps
□ US Navy
□ US Coast Guard
□ US Air Force
□ US Army
□ NC National Guard
3. Please mark your current duty station in North Carolina:
□ Camp Lejeune □ MCAS New River □ Cherry Point □ Other ___________________________
4. If necessary, can you provide documentation of your current duty station if requested by the
college? □ YES □ NO (example: a copy of current orders, a current LES, a copy of your BIR, etc.)
5. Have you been academically admitted to Coastal Carolina Community College? □ YES □ NO
6. Beginning with which academic term are you seeking the tuition benefit? ____________________
Year Term
7. Service Member’s anticipated military separation date: _____/_______/_______
(Those with an indefinite military separation date should use expiration date on military id card) MONTH DAY YEAR
CERTIFICATION BY APPROPRIATE MILITARY AUTHORITY
This is to attest that _________________________________________________ is on active duty at
Last First Middle Initial
__________________________________________.
Duty Station
_____________________________________ _____________________________________
Supervising Military Authority Name/Rank Supervising Military Authority Signature
_____________________________________
Date
***I hereby acknowledge that submission of my Student ID# or Social Security Number is requested by the institution solely for administrative
convenience and record-keeping accuracy, and is requested only to provide a personal identifier for the internal records of the institution.
***I hereby certify that all information I have set forth herein is true to the best of my knowledge, pursuant to my reasonable inquiry where
needed.
***I hereby acknowledge that the institution may verify the information set forth herein from sources accessible under law to the institution
but that the institution may divulge the contents of the application only as permitted under the Family Educational Rights and Privacy Act
(FERPA) of 1974 if I am, or have been, in attendance at the institution.
_____________________________________________________________________________ ________________________________________
Applicant’s Signature Date
**BE SURE THAT THE CERTIFICATION BY APPROPRIATE MILITARY AUTHORITY IS COMPLETED**
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