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NAVAL RESERVE OFFICERS TRAINING CORPS
STUDENT PERFORMANCE AND COUNSELING RECORD
Privacy Act Statement
Authority: The authority to request this information is contained in: 5 USC § 301 (Authorizing Forms and Regulations), and 10 USC, Subtitle A, Part
III, Chapter 103 (Senior ROTC).
Principal Purpose(s): For use by the Naval Reserve Officers Training Corps (NROTC) student advisor for recording general information about
NROTC students and for documenting counseling sessions.
Routine Use(s): Information you provide in this application is protected by the Privacy Act and will not be released outside the Department of
Defense without your permission unless it comes within an exception to the Act or one of the routine uses in 32 CFR § 701.112, accessible at
http://www.privacy.navy.mil.
Disclosure: Failure to provide the requested information may result in removal from the NROTC program and/or loss of scholarship benefits.
STUDENT INFORMATION

FAMILY INFORMATION

Name:

Name of Next of Kin:

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