NSTC 1533-129 (07- Nurse SOU

CERTIFICATIONS AND STATEMENTS OF UNDERSTANDING FOR
NAVAL RESERVE OFFICER TRAINING CORPS NURSE APPLICATIONS

OMB Control Number: 0703-0026, Exp _______________
AGENCY DISCLOSURE STATEMENT

The public reporting burden for this collection of information is estimated to average 3 hours and 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters
Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (OMB Control Number: 0703-0026). Respondents should be aware that notwithstanding any other provision of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.
Responses should be sent to:
Commander
Naval Service Training Command
2601 A Paul Jones Street
Great Lakes, IL 60088
PLEASE READ THE FOLLOWING STATEMENT REQUIRED BY THE PRIVACY ACT OF 1974 BEFORE COMPLETING THE APPLICATION.
1.AUTHORITY: The authority to request this information is contained in: 5 U.S.C. § 301 (Authorizing Departmental Forms and Regulations); 10 U.S.C. § 2107 (Financial Assistance Program); and Executive Order 9397 (Use of Social Security Numbers).
2.PRINCIPAL PURPOSE(S): The information you provide will be used to determine whether you qualify, and should be nominated for, an NROTC Scholarship. If you are nominated, the information will be used to enroll you into NROTC and will be used by the
Navy in its management of the NROTC program. The following systems of records notices cover the collection of this information: N01130-1 located at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570316/
n01130-1.aspx.
3.ROUTINE USE(S): Information provided on the application will be used to screen and select individuals to received NROTC Scholarships, to maintain data on the NROTC scholarship program, to compare to scholarship applicants from previous or
subsequent years, and to provide academic data and contact information to Navy activities and admissions officials at colleges and universities so they can contact applicants for recruitment purposes. Other uses may include providing the information to
officials and employees of: the Department of Transportation; other agencies of the Executive Branch upon request in relation to the management of quality of military recruitment; and the Department of Veterans Affairs and Selective Service Administration in
relation to enlistment or reenlistment eligibility. Information you provide in this application is protected by the Privacy Act and will not be released outside of the Department of Defense without your permission unless it comes with an exception to the Act or one
of the routine uses in 32 C.F.R. § 701.112, http://www.privacy.navy.mil/ and the routine uses set forth here. If you are nominated for an NROTC Scholarship, the information will be released to the top five schools you indicated on your application. Your
information and notification of status may also be provided to your high school so they may assist with the final stages of the process.
4.DISCLOSURE: The social security number (SSN) is required at the time of application to ensure proper identification of the applicants. There are times applicants have the same names, therefore the SSN is required to ensure proper identification. Providing
the requested information is voluntary. However, failure to do so may result in our inability to process your application for the NROTC program.

Please read and initial by each of the following statements below indicating your certification or understanding of each
CERTIFICATIONS
1.

I certify that all of the information that I provided in the electronic application is complete and correct to the best of my knowledge.

2.

I certify that I have no moral obligations, personal convictions or beliefs, which would prohibit my serving in a military status. This includes
supporting and defending the Constitution of the United States against all enemies foreign and domestic.

3.

I certify that I solely composed the essay(s) submitted with my electronic application.
I certify that I desire to apply for the Navy Nurse Corps NROTC Scholarship Program. I understand that by applying to this program that:
·I will not be considered for the regular NROTC Scholarship Program.

4.

·I must major in nursing.
·Any attempt to change my major to something other than nursing will result in loss of scholarship benefits and I may be required and
have an obligation to pay back the government of the United States of America an amount equal to the benefits I received under the
scholarship or serve a period of Active Enlisted Service at the discretion of the Secretary of the Navy.
·This program is for obtaining a Bachelor's of Science degree in nursing only.
STATEMENTS OF UNDERSTANDING

1.

I understand that the information that I have provided electronically is only a partial application, and that I must complete all additional
requirements and achieve qualifying SAT/ACT scores before my application will be processed.

2.

I understand that my scholarship benefits are tied to the Tier 2 Nursing Major. See the following links for details on academic Tier Majors/
Academic Tiers: https://www.nrotc.navy.mil/scholarship_criteria.aspx

3.

I understand that I will receive scholarship benefits for a maximum of four academic years. However, if I receive my Baccalaureate Degree earlier
than four academic years, I shall not be eligible for any further scholarship benefits. See the following links for details on scholarship benefits;
https://www.nrotc.navy.mil/scholarships.aspx

4.

I understand if I enter the NROTC program having already earned college credit, I am expected to use any allowable credits towards my degree to
accelerate the completion of my Baccalaureate Degree.

5.

I understand that upon successful completion of the NROTC program I may be offered a commission in the Navy's Nurse Corps, requiring a
minimum of four years of active military service. If I do not accept my commission I may be required and have an obligation to pay back the
government of the United States of America an amount equal to the benefits I received under the scholarship or serve a period of Active Enlisted
Service at the discretion of the Secretary of the Navy.

6.

I understand that that I will be required to sign and agree to the terms in the NROTC Scholarship Contract (NSTC 1533/135) upon activating my
scholarship when I report to my assigned NROTC unit.

7.

I understand that if any of the information I provided herein or in any part of my application is inaccurate, false or misleading, it may result in my
non-selection for an NROTC scholarship and make me ineligible for continued participation in the NROTC program.

Warning: Any intentionally false or misleading statement, certification, or response you provide is a violation of the law punishable by a fine of not more than $10,000, or imprisonment of not more than
5 years, or both (18 U.S.C. § 1001).

Signature of Applicant

Signature of Witnessing Official

Printed Name of Applicant

Printed Name of Witnessing Official

Date
NSTC 1533/129 (07-16)

Date