ADMINISTRATIVE INFORMATION FOR SCHOLARSHIP STUDENTS

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1 ADMINISTRATIVE INFORMATION FOR SCHOLARSHIP STUDENTS 2014

2 SCHOLARSHIP ADMINISTRATIVE CHECKLIST Make sure to fill out each form to the best of your ability, and then present the forms at orientation either on 9 August 2014 or 22 August 2014 (whichever date of orientation you will be attending). Copies of the completed documents should be made for your own records. Please return the completed forms and photocopies of the required personal information at orientation. If you are not planning on participating in NROTC, please contact us immediately at (203) 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 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 Naval Branch Health Clinic Registration Form Navy Tattoo Screening Form NROTC Scholarship Service Agreement Privacy Act Statements (2 copies) both need original signature Report of Dental Examination SGLI, Servicemember s Group Life Insurance Election The Concept of Honor 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 Copy of vaccination records (may also be faxed or ed 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 with questions Phone: (203) Fax: (203) Website: 1

3 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: 9 August 2014 or 22 August 2014 (whichever date of orientation you will be attending). 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 9th day of August, 2014 or 22 nd day of August, (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 (9 August 2014 or 22 August 2014). 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 / Blocks 10 and 11: Use permanent address and phone number Blocks 14 through 17: Fill out accordingly. Block 18: disregard Blocks 23 & 24: Fillout 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 12: disregard. Section I, Blocks 13 through 26: self explanatory. Section I, Blocks 27 through 32 & Section II: disregard. Section III, Blocks 90 and 91: Read and sign and date ( or ). Leave the rest of the form blank. 2

4 Authorization for Release of Student Information Authorization for Release of 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 I. Sign with full name: first, middle, and last. Date: 9 AUG 2014 or 22 AUG Under signature, write in the last four digits of your social security number or your college ID number. Authorization for Release of 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 I. Sign with full name: first, middle and last. Date: 9 AUG 2014 or 22 AUG Under signature, write in the last four digits of your social security number or your college ID number. Authorization for Release of Information- Unit to Parents This document authorizes release of information from the unit to your parents. After Midshipman, print 4/C, followed by your first, middle, and last name. Sign with full name: first, middle, and last. Date: 9 AUG 2014 or 22 AUG Under signature, write your year of graduation The signing of this document is voluntary. If you choose not to authorize the Unit to release information to your parents please write Decline on the form and initial it. 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. 3

5 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 13b: Sign with full name. Section D, Block 13c: Date with the date or Section E, Block 15: Fill in your full name. Section E, Blocks 16 & 17: leave blank. Section E, Blocks 18a and 18b: Sign and date or 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. It is required to ensure you are afforded support services for summer cruise. 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, 57, and 60, 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: 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. 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. 4

6 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 9 AUG 2014 or 22 AUG 2014 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. 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. Sign and date the document: 9 AUG 2014 or 22 AUG All of the other information that is asked for should be self-explanatory concerning your personal information. We will review this document at Freshman Orientation to confirm your understanding and certify that your signature is true. 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: or 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 or 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 or 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. 5

7 Naval Branch Health Clinic Registration Form In the Sponsor Information section you only need to fill out the blocks Name, DOB, SSN, Branch, Rank, Status, and Sex. The Blocks for Name and DOB should be self-explanatory. For the SSN block please write your full social. For the Branch block: Navy Option Midshipmen should circle USN, Marine Option Midshipmen should circle USMC. For the Rank block please write MIDN. For the Status block please circle Recruit/Applicant. Please indicate your sex in the Sex block. All remaining blocks have either been completed for you or are not necessary. Self-explanatory Navy Tattoo Screening Form 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 (9 AUG 2014 or 22 AUG 2014) 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 9 AUG 2014 or 22 AUG 2014, 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: 9 AUG 2014 or 22 AUG Print, sign and date TWO copies (one for health record and one for dental record). 6

8 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 ed to the Unit directly from your dental provider s office. SGLI (Servicemember 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 ( or ). 7

9 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 9 AUG 2014 or 22 AUG 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. 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 Copy of vaccination records (may be faxed or ed 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

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