CC FORM 167-R, OCT 2005
PREVIOUS EDITIONS ARE OBSOLETE
U. S. ARMY ROTC SCHOLARSHIP ACCEPTANCE/DECLINATION STATEMENT AND PMS VALIDATION
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
Authority 10 USC 2101 and 2107.
Principal Purpose(s) To notify ROTC Cadet Command that winner accepts or declines a scholarship offer. Notifies which institution winner
will attend and reason if scholarship offer is declined.
Routine Uses To maintain count of acceptances/declinations to enable ROTC Cadet Command to make awards to alternates. Information on
the institution is obtained to identify enrollment and allocation of funds to pay costs. Information is also used to mail medical
forms to be included in the cadet personnel file. Information on why recipient declines is maintained for statistical studies of
enrollment trends. Information is used by ROTC Cadet Command and to provide specific data to ROTC Regions and PMS.
Disclosure Mandatory or voluntary disclosure and effect on individual not providing information - all data is mandatory. Individuals
who do not notify ROTC Cadet Command of acceptance will lose their scholarship.
1. NAME OF INSTITUTION 2. SCHOOL CODE (FICE CODE)
3. NAME OF WINNER (Last Name, First Name, MI) 4. SOCIAL SECURITY NUMBER (no dashes)
5. SCHOLARSHIP TYPE (check one)
2-Year Campus Based
2-Year Graduate Program
2-Year GRFD-ARNG
2-Year Dedicated ARNG
2-Year GRFD-USAR
2-Year Leader's Training Course (LTC)
2-Year Military Junior College (MJC)
2-1/2 - Year GRFD-ARNG
3-Year (or 2-1/2-Year) Campus Based
3-Year GRFD-ARNG
3-Year Green to Gold
2-Year Green to Gold
2-Year Graduate Green to Gold
3-Year Advance Designee (AD)
4-Year (or 3-1/2-Year) Campus Based
4-Year Green to Gold
4-Year High School
6. DECISION:
ACCEPT DECLINE
7. REASON FOR DECLINATION:
1 - Commitment
2 - Academic Major Restriction
3 - Non-Military Scholarship
4 - Other Military Scholarship
5 - ROTC Too Time Consuming
6 - No Longer Interested
7 - Other (Please explain)
8. SIGNATURE 9. DATE
I, the undersigned, hereby acknowledge receipt of notification of my selection for the award of an Army ROTC Scholarship. In accepting this
scholarship I understand that I will obtain a degree in the academic major indicated on my application/contract or I may lose my scholarship if I
change to another academic discipline without prior written consent of the Professor of Military Science.
PMS VALIDATION OF 3- AND 2-YEAR ADVANCE DESIGNEES
(TRANSCRIPT MUST BE INCLUDED FOR VALIDATION)
1. GPA, Academic
Cumulative
2. GPA, ROTC
Cumulative
No more than 4.0 will be entered. If other than a 4-point
scale, convert using the table in CC Reg 145-1.
3. MAJOR SUBJECT:
ACADEMIC MAJOR CODE :
4. STATUS OF MEDICAL QUALIFICATION:
Qualified
Has Changed (Physical submitted to DoDMERB)
Not Recommended
Recommended
5. PMS RECOMMENDATION:
6. PROJECTED GRADUATION DATE (YYYYMM):
7. SCHOLARSHIP AWARD DATE(YYYYMMDD):
8. PMS REMARKS:
SIGNATURE OF PMS DATE (YYMMDD)
