NSTC 1533-155 Counselor Request for Transcript

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.

NSTC 1533/155 (07-16)

REQUEST FOR SECONDARY SCHOOL TRANSCRIPT
Applicant’s full name (Last, First Middle)_______________________________________________________________
Birth Date: _____________________________________________ NROTC Program Option: ____________________
Social Security Number: __________________________________
The student named above is applying for an NROTC Scholarship. Please complete this part of the form as accurately as possible. The
Scholarship Selection Board uses a transcript of grades in reviewing an applicant’s record.
1. In addition to courses taken (or in progress) and grades received, it is essential that the transcript reflect rank in class along with the
most complete academic record to include test results such as NMSQT, CEEB’s ACT’s and other national examinations.
2. IMPORTANT! Please submit this information immediately.
3. Return completed form and a transcript signed or stamped by a high school official to the recruiting activity indicated on the selfaddressed envelope provided (Also, include a profile of the graduating class, if possible.)
4. I authorize release of my high school transcript.

___________________________________________________________
Signature

Date:______________________

1. Candidate’s GPA: Weighted (ex. 999.99) ________________________ Unweighted (ex. 9.99) __________________________
2. GPA Scale:

Weighted (ex. 999.9) _________________________ Unweighted __________________________________

3. Rank in Class (Approx. to nearest 10th from top): __________ Exactly or Approximately
Rank from Top: ________________ No. in Class: _________________
4. % Grad Class Expected to Enter: 4-Year College: _________________

2-Year College: _________________

5. School ETS Code: _______________
6. Did this student take any:
Type of Class
Honors Courses

Yes

No

Not Offered

Accelerated Courses
Advanced Placement Courses
Dual Enrollment Courses
International Baccalaureate
7. Are all honors, accelerated and advanced placement courses given extra credit in computing GPA:
Yes

No

Rank in Class
Grade Averages
8. Did the student receive any academic accommodations? (i.e., extra time on tests, established 504 plan): Yes/No
If yes, please list the type of academic accommodations received and the school year(s) received.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

NSTC 1533/155 (07-16)

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9. Is applicant from minority group or disadvantage background? Yes/No
If yes, which? Minority/Disadvantaged (specify in comment area)
10. Official School Name: _____________________________________________________________________
Street Address: ____________________________________________________________________________
City: ____________________________________ State: ______________________ Zip Code: ___________
School Telephone (Include area code) ______________________________________
11. Ranking Period: From ________________ to ___________________
Indicate how grade point average and rank were determined if profile is not available.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
12. If rank is not available, please indicate placement by percentile below:
[] Top 5%
[]

Top 10%

[]

Top 20%

[]

Top 30%

[]

Top 40%

[]

Top 50%

[]

Lower 50%

13. Comment: (Additional information which may be significant in considering applicant).
______________________________________________________________________________________________
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_____________
Date

__________________
Title

NSTC 1533/155 (07-16)

___________________________________
Signature

______________________
Print Name

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