Fillable NROTC Preparatory Program Scholarship Application (Illinois Institute of Technology)

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NROTC Preparatory Program Scholarship Application (Illinois Institute of Technology)

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NROTC Preparatory Program
Scholarship Application
Application Checklist
Illinois Tech
NROTC Preparatory Scholarship Application
High School Transcript
and SAT/ACT Official Report
Letters of Recommendation (SNSI recommendation required if NJROTC)
Report of Medical History, signed by your physician (do not include social security number)
Apply to
Illinois Tech through the Common Application
Drug Statement
Official Applicant Fitness Assessment (AFA) Score Sheet
Completed Annual Certificate of Physical Condition
Instructions
If you have an
y questions, please do not hesitate to contact:
LT Joshua Smith
10 W 35th Street
Tower Building, 15th Floor
Chicago, IL 60616
Phone: 312.567.8963
Email: NROTC@iit.edu
1. Submit your application and supplemental materials to Illinois Tech through the Common App.
2. Download the Presidential NROTC Preparatory Scholarship Application form, the AFA scoring sheet, the Report of Medical
History, Report of Medical and the Drug Statement at https://admission.iit.edu/NROTC
3. Fill out the NROTC application form by typing directly into the document. Once completed, print out the application and sign
it using pen.
4. Upload the following signed and completed forms to https://admission.iit.edu/NROTC:
- Presidential NROTC Preparatory Scholarship Application form
- Drug Statement
- Report of Medical History
- Report of Medical Examination
5. Have a coach at your school, or your Senior Naval Science Instructor administer the AFA and email the signed copy of the
AFA score sheet to ugaprocessing@iit.edu. This should be sent in by the person who administered the test, not by the applicant.
6. You must obtain a letter of recommendation from either your SNSI or a Math or English teacher. Additional letters of
recommendation from other sources are encouraged but not required. All letters of recommendation must be emailed by the person
writing the recommendation to ugaprocessing@iit.edu
Apply for Free Application for Federal Student Aid (FAFSA) Illinois Tech ID: 001691
Report of Medical Examination, signed by your physician (do not include social security number)
Personal Information
Please enter your name as it appears on your passport or other official documents.
Name Date of Birth
Last (Family) First Middle Suffix (Jr., Sr., etc.) (mm/dd/yyyy)
Legal Sex: Male
Female
Preferred Name Previous Last Name(s), if any
Email Intended Major or Area of Study
Permanent Address
Street Address Apt. #
City/Town State/Province Country Zip/Postal Code
Phone Alternate Phone
Begin with Area or Country Code Begin with Area or Country Code
Citizenship
Place of Birth
City/Town State/Province Country
US Citizen Dual US citizen; please specify other country of citizenship
US permanent resident visa; citizen of Alien registration number
Other Citizenship
Visa
If you live in the United States, but are not a U.S. citizen, how many years have you lived in the country?
If not English, language spoken in your home If not English, list your first language
Ethnicity
Race/Ethnicity information is optional. Information you provide will not be used in a discriminatory manner and will not be used as a factor
for selection or disqualification.
Are you Hispanic or Latino? Yes No (country of family’s origin
)
How would you describe your racial background? (select one or more of the following categories):
Asian (country of family’s origin ) Native Hawaiian or Other Pacific Islander
Black or African American White
American Indian or Alaska Native (enrolled )
Tribal affiliation )
NROTC Preparatory Program
Scholarship Application
Academic Information
School CEEB Code
Type of school: Public Private Correspondence Charter Parochial Home-School Other/Education Provider
School Address
Number and Street
City/Town State/Province Country Zip/Postal Code
Start Date Date of Graduation
(mm/yyyy) (mm/yyyy)
Counselor’s Name Phone
Begin wit h Area or Country Code
Counselor’s Email Fax
Begin with Area or Country Code
Are you currently enrolled in school? Yes No Will/did you graduate from High School early? Yes No
Current Year’s Courses
Please list name, level (Honors, AP, IB, etc.) and credit value of your current year’s courses.
Semester #1/Trimester #1 Semester #2/Trimester #2 Trimester #3
List all other high schools, colleges/universities (including summers), and academic programs you attended, beginning with ninth grade. You
must submit transcripts from each school.
Other High Schools
School Name CEEB Code Dates Attended Location
Colleges/Universities
School Name CEEB Code Dates Attended Location
NROTC Preparatory Program
Scholarship Application
Academic Information
Please list any Advanced Placement or International Baccalaureate exams taken along with the test date and score.
Test Date Subject Score Test Date Subject Score
Test Date Subject Score Test Date Subject Score
Test Date Subject Score Test Date Subject Score
Standardized Test Information
List your test scores below. You must have the testing agency send official scores to each institution to which you are applying.
SAT Reasoning
Test Date Evidence Based
Reading & Writing
Math Optional Essay Test Date Evidence Based
Reading & Writing
Math Optional Essay
SAT Subject
Test Date Subject Score Test Date Subject Score
Test Date Subject Score Test Date Subject Score
ACT
Test Date English Math Reading Science Composite Optional Essay
Test Date English Math Reading Science Composite Optional Essay
Test Date English Math Reading Science Composite Optional Essay
ASVAB
Test Date AFQT Score Test Date AFQT Score
Academic Distinctions
Please list any academic or educational awards and honors you received in high school (e.g. National Merit, National Honor Society).
NROTC Preparatory Program
Scholarship Application
Extracurricular Information
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. Examples: NJROTC, Student Government, Eagle Scout, etc...
Activity/Org
anization Specific Accomplishments/ Positions Held Grade Level(s) Hours/Week Weeks/Year
9 10 11 12 |
9 10 11 12 |
9 10 11 12 |
9 10 11 12 |
Athletic Activities
READ CAREFULLY: Identify only those sports in which you engaged during school grades 9-12. Mark the year(s) in which you were on the varsity team. If you
lettered in the sport list that in the awards. Mark 'JV/Club' if you participated at this level in any year. If you will play a sport in college, check the box under
'College.' Do not list intramural activity.
Sport Positions
Held Awards/Recognition Grade Level(s) JV/Club College
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
Employment Information
List any work experience (including summer jobs) during the past three years.
Employer Job Description Dates of Employment Hours per week
NROTC Preparatory Program
Scholarship Application
Volunteering
READ CAREFULLY: Identify only those volunteering activities in which you engaged during school grades 9-12. List the number of hours performed per year next to the
box corresponding to the correct school year and volunteer activity. Attach additional sheets if more space is needed.
Activity Description/Remarks Grades/Hours
9 10 11 12
9 10 11 12
9 10 11 12
9 10 11 12
1. Are you a (check
all that apply) Veteran Dependent of US Veteran Active US Military National Guard or Active Reserve
2. If you are/were a part of the military, which branch (check all that apply) Army Navy Air Force Marines Coast Guard
3. Are you applyi
ng to any service academies or other ROTC programs? Yes No
(If so, please list all in the additional information section.)
4. Have you ever been rejected for any reason for service in any branch of the military? Yes No
(If so, please describe fully in the additional information section.)
5. Would you be willing to attend any university with a similar program resulting in a Naval Commission? Yes No
6. Are you going to be a first generation college student? Yes No Mother Father Sibling Aunt Uncle Cousin
(If “no”, please indicate relatives who have completed a 4-year degree)
Family
Information
If you have any family member(s) or legal guardian(s) who has served or is/are currently serving in the military, please indicate below.
Parent/Legal Guardian Military History (More room available in "Additional Information")
Name (relationship)
Branch
Rank/Rate
Status (Active/Retired)
Commissioning Source if Applicable
Physical Fitness Information
Applicant height
(feet, inches): ________
Applicant w
eight (lbs): ________
AFA Information:
(The official score sheet for the AFA will be submitted separately)
1.
Crunches: ______________________________
2.
Push-ups: ______________________________
3.
1 mile run time: ______________________________
4.
Observer name, position: ______________________________
5.
Observer phone number: ______________________________
NROTC Preparatory Program
Scholarship Application
Additional Information
If you have additional information that was not specifically requested on the application or did not fit in the space provided, feel free to include it here. If
you need more space, please attach your response to the end of the application.
Please answer the following ques
tions. Provide explanations for “yes” replies in the additional information section below.
Yes No
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 'Yes', list the date, place of application, program applied for and current status of application.)
2. Have you signed an Enlistment Contract (DD Form 4) with any of the Armed Forces of the United States? (If 'Yes', list the date, place, service,
and current status of enlistment.)
3. Have you ever been arrested, detained, indicted, summoned into court, or convicted for any violation of civil or military law, including juvenile
offenses and moving traffic violations? (If 'Yes', give complete description of incident, name and place of court, nature of offense, date, and
disposition)
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 'Yes', explain in affidavit form and submit
with application, even if differences were only differences in spelling.)
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 'Yes', attach a statement
with the full circumstances, number of time 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 'Yes', attach a statement with the full circumstances, number of times used, amoun
ts taken, period over which taken, and
intent for further use.)
NROTC Preparatory Program
Scholarship Application
Service Community
Which service community are you most interested in joining in the Navy and why? If you are not selected for that community, would you still accept your
commission as a Naval Officer. Limit responses to 250 words.
NROTC Preparatory Program
Scholarship Application
Essay Response
Discuss your reasons for wanting to become a Naval Officer. Specifically comment on leadership positions you have held, the challenges you have faced, and the lessons
you have learned. Limit your response to 500 words.
NROTC Preparatory Program
Scholarship Application
Medical History (If you answer “yes,” please provide explanation in block 41.)
Yes No
1. Eye trouble (to include vision loss, cataract, glaucoma, keratoconus, corneal ectasia, retinal detachment)?
2. Surgery to improve vision (PRK, LASIK, LASEC, RK, intraocular lens implant, cross linking)?
3. Color vision deficiency?
4. Ear trouble (to include perforated ear drum, tubes in ears, or other ENT surgery)?
5. Loss of balance or vertigo?
6. Hearing loss or use of a hearing aid?
7. Nose, throat, or sinus trouble (to include sinusitis, abscess, surgery on nose, sinuses or throat)?
8. Orthodontic treatment? (if "yes", include completion or projected date of completion in block 41)
9a. Tooth or gum trouble (excluding cavities)?
9b. Date of last dental exam:
10. Breathing trouble (to include asthma, wheezing, shortness of breath, chronic cough, use of inhaler, collapsed lung)?
11. Cardiac trouble (to include chest pain, palpitations, heart valve problems, surgery, high or low blood pressure)?
12. Gastrointestinal trouble (to include celiac disease, irritable bowel syndrome, ulcer, reflux, esophagitis, gallstones, hernia, or
hepatitis)?
13. Inflammatory bowel disease (to include Ulcerative colitis or Crohn's disease)?
14a. Gynecologic trouble (including endometriosis, polycystic ovarian disease, abnormal pap smear)? (females only)
14b. Date of last menstrual period (females only):
14c. Date of Last PAP smear (females only):
15. Testicular or prostate trouble? (males only)
16. Orthopedic problems of the back or neck?
17. Orthopedic problems of the upper extremities (fracture, dislocation, sprain, surgery)?
18. Orthopedic problems of the lower extremities (fracture, dislocation, sprain, surgery)?
19. Vascular trouble (Raynaud's disease, blood clot or deep venous thrombosis, high blood pressure)?
20. Skin trouble (to include psoriasis, eczema, atopic dermatitis, severe acne)?
21. Prescribed systemic retinoid medications (i.e.: Accutane)? (List date completed or projected completion date in block 41.)
22. Blood disorders (anemia, thrombocytopenia, bleeding disorders, disorder of the spleen)?
23. Allergic reaction to food, medications, insects?
24. A positive PPD or been treated for tuberculosis?
25. Car, train, sea, or air sickness that required prescription medication or avoidance of travel?
26. Endocrine disorders (including diabetes, thyroid, osteoporosis)?
27. Head injury, memory loss, amnesia?
28. Neurologic trouble (including dizziness, fainting spell, seizure, paralysis)?
NROTC Preparatory Program
Scholarship Application
Medical History (Continued)
Yes No
29. Frequent or severe headaches in the past 2 years?
30. Sleeping trouble (narcolepsy, sleepwalking, chronic insomnia, sleep apnea)?
31. Evaluation or treatment for depressive disorder?
32. Evaluation or treatment for anxiety disorder or panic attacks?
33. Evaluation or treatment for eating disorders (anorexia or bulimia)?
34. Evaluation or treatment for attention deficit hyperactivity disorder, attention deficit disorder, or learning disability?
35. Tumor or cancer?
36. Cold or heat injury?
37. Rhabdomyolysis?
38. Have you been prescribed medications in the last 12 months? (if "yes" list names, reason, and approximate dates used in Block
41)?
39. Have you EVER been hospitalized (including psychiatric)?
40. Have you EVER been rejected or discharged for military service for any reason?
Medical Comments
41. Explain all “yes” answers to questions 1-40 above. Begin with the Item Number. Describe answer(s): provide date(s) of problem(s) /condition(s);
provide names of Health Care Providers (HCPs), Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation
and/or treatment); and describe your current medical status (ongoing/resolved). Attach additional sheet(s) if necessary and s
ign and date each additional
page. Obtain and attach copies of applicable medical evaluation and treatment records if requested.
I certify that all medical information provided by me is complete and correct to the best of my knowledge.
Applicant Signature
Date
NROTC Preparatory Program
Scholarship Application
Please read an
d initial by each of the following statements below indicating your understanding of each.
After initialing all statements, please sign and date at the bottom of the page.
Statements
1. University will provide tuition*, fees, and room & board for a one-year NROTC preparation program as a
Midshipman Candidate.
2. Provided you meet the criteria below, you will be awarded a National NROTC scholarship to the
University at the conclusion of your first year:
a. Science/Technical major (Tier 1 / Tier 2 - 15 majors available).
b. Maintain greater than 2.8 minimum GPA.
c. Pass the Navy Physical Fitness Assessment once a semester with a score of "Good Low" or better.
d. Reside at university (dormitories).
e. Maintain Navy Bureau of Medicine and Surgery (BUMED) medical standards
3. Upon completion of the first year, you will be financially responsible for room & board costs (competitive
room & board scholarships are available).
*Scholarship provides for in-state tuition only. Out-of-state applicants are welcome to apply and can qualify for in-state tuition through the Academic Common Market
program for their state. https://www.sreb.org/academic-common-market
Verification
Your signature below confirms all information in this application (including any supplemental information) is factually true and honestly presented and that you are the
person submitting this application.
Signature of applicant Date
NROTC Preparatory Program
Scholarship Application
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NROTC Preparatory Program Scholarship Application (Illinois Institute of Technology)

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Completed 23 July 2020

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