ADMINISTRATIVE INFORMATION FOR SCHOLARSHIP STUDENTS 2013
SCHOLARSHIP ADMINISTRATIVE CHECKLIST Make sure to fill out each form to the best of your ability, and then return the forms via regular mail. Copies of the completed documents should be made for your own records. Please return the completed forms and photocopies of the required personal information no later than 07 August 2013. If you are not planning on participating in NROTC, please contact us immediately at (203) 432-8223 and do not fill out any paperwork. Please refer to the instructions included in this document. Forms to be filled out: Acceptance and Oath of Office Annual Physical Condition Certificate Application for Uniform Services ID Card Authorization for Release of Student Information to Parents Authorization for Release of Student Health Information Authorization for Release of Student Academic Information-School to Unit DD-4, Enlistment-Reenlistment Document Dependency Application/Record of Emergency Data Direct Deposit Sign-Up Form Drug and Alcohol Abuse Statement of Understanding MCRC Officer Tattoo Screening Form Marine Option ONLY Midshipman Background Information Sheet Navy Tattoo Screening Form NROTC Scholarship Service Agreement Privacy Act Statements (2 copies) both need original signature Report of Dental Examination The Concept of Honor SGLI, Service members Group Life Insurance Election Required Personal Information: Mail copies of the following with the forms above. Blood Type Identification (Doctor or Red Cross card) Original or Certified copy of Birth Certificate (certified copy with raised seal) Copy of Social Security card with signature (may also be scanned and emailed) Copy of vaccination records (may also be faxed or emailed directly from your physician to the NROTC Unit) Copy of current health insurance card (both front and back) Copy of prescription insurance card (if you have one) Contact the Yale NROTC Unit Phone: (203) 432-8223 Fax: (203) 432-8951 Email: nrotc@yale.edu Website: http://nrotc.yalecollege.yale.edu/ 1
Instructions for Administrative Forms These forms are required for entry into the NROTC Program at Yale. The dates on these forms should reflect the first day of Freshman Orientation: 23AUG 2013. Please return the completed forms and required personal information no later than 07 AUG 2013. Acceptance and Oath of Office Print your full name with first, middle, and last, after the letter I. After Midshipman, circle USNR for Navy Option, USMCR for Marine Corps Option. The date should read 23 rd day of August, 2013. (No other date should be inserted.) Sign above Appointee Signature. You should sign using your first, middle and last name. Complete this for both Acceptance and Oath of Office sections. Leave the Witnessing Officer lines blank. Annual Certificate of Physical Condition Write date at the top of the document (23 AUG 2013). Blocks 1 and 2: self- explanatory, use last four of SSN Block 3: MIDN Block 4: disregard Block 5 through 8: self- explanatory Block 9: NROTC Yale / 63292 Blocks 10 and 11: Use permanent address and phone number Blocks 12 through 17: Fill out accordingly. Block 18: disregard Blocks 23 & 24: Fill out accordingly. Block 19, for females only. Leave other blocks blank unless you possess a record of the information requested. Answer the questions on page two truthfully and sign first, middle, and last name next to Member s Signature. Application for Uniform Services ID Card Section I, Blocks 1 through 3: self-explanatory. Section I, Blocks 4 through 7: disregard. Section I, Blocks 8 through 20: self-explanatory. Section I, Blocks 21 through 23 & Section II: disregard. Section III, Blocks 24 through 28: self-explanatory. Section III, Blocks 29 through 31: disregard. Section III, Blocks 32 & 33: self-explanatory. Leave the rest of the form blank. 2
Authorization for Release of Student Information to Parents This document authorizes release of Student Information to Parents. Print your first, middle, and last name after 4/C. Sign with full name: first, middle, and last. Date: 23 AUG 2013. Under signature; your graduation year will be 2017. Authorization for Release of Student Health Information This document authorizes release of your sports physical, held by your school s health service, to the unit. Print your first, middle, and last name after 4/C. Sign with full name: first, middle, and last. Date: 23 AUG 2013. Under signature, write in the last four digits of your social security number or your college ID number; for the class of, it will be 2017. Authorization for Release of Student Academic Information- School to Unit This document authorizes release of student information from your respective university to the Yale NROTC unit. Print your first, middle and last name after 4/C. Sign with full name: first, middle and last. Date: 23 AUG 2013. Under signature, write in the last four digits of your social security number or your college ID number; for the class of, it will be 2017. DD-4 Enlistment-Reenlistment Document Section A, Block 1 and 2: self-explanatory. Section A, Block 3: Home of Record, fill in your permanent physical address (not a PO BOX or school address). Section A, Block 6: Date of Birth (YYYYMMDD). Section A, Block 7: If you have previous active or inactive military service, fill out block 7. If not, disregard. Section B, Blocks 8a and 8b: disregard. Section B, C, and E: initial bottom left hand corner of each section where it reads (Initials of Enlistee/Reenlistee) Above Section D: Insert your name and social security number at the top of the form. Section D, Block 13 and 14: leave blank. Section E, F, G and H: disregard This form does not obligate you to any service. You have until the end of your first year to decide whether or not you wish to continue with the program. 3
Dependency Application - Record of Emergency Data Blocks 5 through 32: Only apply if you have a spouse and/or dependents (otherwise disregard). Blocks 33 through 38: self-explanatory. If addresses for parents are the same, fill in father s address and write same for your mother. Block 39: If NO, Disregard to Block 53. If YES, fill out appropriate blocks. Blocks 53 through 63: choose a beneficiary for your pay and allotments should something happen to you. Be sure to fill out subsequent blocks for address/relationship/% allotment for each beneficiary. NOTE: Should only be immediate family such as parents or siblings. Block 64 through 66: If you have personal life insurance, put this data here. *Does not include SGLI. Block 67: Fill in your preferred religion. If none, write No Preference. Block 68 through 72: disregard Blocks 73 and 74: Print last, first, and middle name and SSN. Block 77: Fill in location of a will or other valuable papers; or Disregard. Block 78: PNOK is your primary next of kin, and SNOK is your secondary next of kin. Fillin a PNOK and a SNOK. For address, you may enter See Block 34 if PNOK is father, and See Block 37 if SNOK is mother. If listing NOK other than parents, write in the new address. Add telephone numbers with area code. Block 79: Sign in the block and print name in the space under signature block. (First, Middle, Last Name, USNR) Direct Deposit Sign-Up Form Section 1, Block A and B: Fill in appropriate information. Use your permanent address and your name for Payee and Name of Person Entitled to Payment Section 1, Block C: Fill in with your social security number. Section 1, Block D: Specify whether the account to which the funds will go is checking or savings. Section 1, Block E: Should be filled in with personal account information, found on your bank statement or personal check. Section 1, Block F: Check Other and write Military Reserve in the space next to it. Under the section titled PAYEE/JOINT PAYEE CERTIFICATION sign your full name in the appropriate box and insert 23 AUG 13 for the date. Section 2: disregard. Section 3: Fill out the name and address of your financial institution and the routing number, found on your personal check. Financial Institution Certification is optional or provide a voided check. 4
Drug and Alcohol Abuse Statement of Understanding Print your first, middle, and last name. Read each section carefully and understand the importance of each statement. Initial with first, middle, and last initial in the box next to the statement (Blocks 1-5a). Note: 5b disregard. Under Certification: Print last, first, middle name, and write your social security number. Do not Sign and date the document until in front of official witness. We will review this document at Freshman Orientation to confirm your understanding and certify that your signature is true. All of the other information that is asked for should be self-explanatory concerning your personal information. MCRC Officer Tattoo Screening Form MARINE OPTION ONLY Purpose of this form is to certify that you have disclosed the full extent of any tattoos, brands or body ornamentation to include those removed or altered. Print your first, middle, and last name. Date: 20130823 Part I, Question 1: Read and answer the question using your First, Middle, and Last Initials. If the answer to Question 1 is No, proceed to Part II; sign and date 20130823. Disregard Part III, IV, and V. If the answer to Question 1 is yes, continue answering Questions 2 through 9. Sign and date Part II 20130823. NOTE: if the answer to Question 1 is yes you must be interviewed by a commissioned officer upon arriving at Unit. Midshipman Background Information Sheet Self explanatory Fill in Campus Data section if information is known, otherwise disregard until Orientation. Self explanatory Navy Tattoo Screening Form 5
NROTC Scholarship Service Agreement Read each section carefully to fully understand the scope of your scholarship. Fill in your Last, First, and Middle name in section immediately following the Privacy Act Statement on Page 1 of 5, followed by your Social Security Number. Fill in Yale University as the school you will attend. Check in which Tier your academic major is aligned and which NROTC program. Fill in your name and address under the Student section of Page 4 (right side of page). Sign and Date (23 AUG 13) the top line on page 5, followed by your date of birth on line 2, and lastly print your full name (First, MI, Last) on line 3. If you are under 18 years of age on 23 August 2013, your Parents (or Guardians) will need to sign the following section on the first day of Orientation. Privacy Act Statement Read each section carefully to understand the reasoning for documenting health care. Sign the form with your first, middle, and last name. Fill in your social security number (last four) and date: 23 AUG 2013. Print, sign and date TWO copies (one for health record and one for dental record). Report of Dental Examination Blocks 1 & 2: Self-explanatory. Blocks 3-16: Must be completed by dentist. If a dental exam has taken place within the last year a new exam is not necessary. This form may be faxed or emailed to the Unit directly from your dental provider s office. The Concept of Honor Be sure to read and understand the significance of this document. Sign your full name: first, middle, and last above Signature of midshipman. Date the form 23AUG 2013. 6
SGLI (Service member s Group Life Insurance) In Section 1, print your Name (First, Middle, Last), print MIDN in the Rank box, followed by your Social Security Number. Print NROTCU Yale in the Duty Location box and USNR or USMCR in Branch of Service block. Read the following prior to selecting a box in Section 1: You will only benefit from this insurance when you are on active duty for summer cruise. If you elect to participate, the premium will automatically be deducted from your pay during summer cruise. To elect full $400,000 coverage, check the block for Name or update my SGLI beneficiary To elect less than full coverage, check the block for Reduce my SGLI coverage to and select an amount. To decline coverage, select Decline (cancel) SGLI coverage and follow the instructions. In Section 3, write in your primary beneficiary or beneficiaries, to include their social security number (if available) and their relationship to you. Fill in the share that each of these people will be given. If you only have one beneficiary, the amount will be 100%. You can choose to divide this up into any fractions you wish. There are 2 payment options of equal monthly payments or a lump sum. Both options pay out the entirety of your coverage. Also in Section 3, choose a secondary beneficiary or beneficiaries in the event your primary beneficiary or beneficiaries are unable to receive the insurance money. NOTE: The percentages under Primary should add up to 100% and the percentages under Secondary should add up to 100%. In Section 4, fill in your Date of Birth, weight, height, and gender followed by checking the appropriate blocks for the medical questions. In Section 5, sign your full name followed by your Social Security Number and the date (20130823). 7
Instructions for Required Personal Information These documents are required for entry into the NROTC Program at Yale. In most cases, photocopies of the original documents will be sufficient, except for proof of citizenship. See specific guidance below. Please mail photocopies of the original documents no later than 07 August 2013. Blood Type Identification (Doctor or Red Cross card), required for all summer training evolutions. Original or Certified copy of Birth Certificate (certified copy with raised seal). Mail a photocopy, and plan on mailing or bringing the original document with you to Orientation. We will immediately return the original to you if mailed. We will need to see (in person) the original or certified copy of your Birth Certificate (FS 240, or DD 1350 for citizens born abroad), so that we can certify the copy for our records as a true copy. Birth certificates must meet all of the following criteria: Full name (first, middle, last), birth date, birth place, birth record validation such as an original or machine produced signature or raised, impressed, embossed, multicolored seal or stamp, or a combination of these is acceptable. Copy of Social Security card with signature (may be scanned and emailed) Copy of vaccination records (may be faxed or emailed directly from your physician to the NROTC Unit) Copy of current health insurance card (both front and back) Copy of prescription insurance card (if you have one) 8