Army ROTC

Department of Military Science & Leadership

Forms


Initial Enrollment Forms

In order 'enroll' in Army ROTC and fully participate in all program training, the following documents must be completed in full.  No obligation is incurred by enrolling, the process only confirms your eligibility to pursue a commission (should you later decide to do so) and provides Workers Compensation coverage should you be injured during official ROTC training events.

1.)  CC Form 104-R (Blank Copy) & (Example) - Planned Academic Program Worksheet

  • In order to complete the 104-R, a signature from an Academic Advisor is required:
    • CAFES: (805) 756-7574, Building 74M-A
    • CAED: (805) 756-1325, Building 5, Room 210
    • Engineering: (805) 756-1461, Building 40, Room 111
    • Business: (805) 756-2601,  Building 3, Room 100A
    • Liberal Arts: (805) 756-6200, Building 47, Room 36C
    • COSAM: (805) 756-2615, Building 53, Room 211

2.)  CC Form 139-R - Cadet Application and Enrollment Record

  • You will need to present an original copy of your birth certificate and social security card in order to complete the 139-R.

3.)  CC Form 137-R - Authorization for Access to Student Records 

4.)  CC Form 136-R - Briefing on Government-Sponsered Benefits for ROTC Cadets

5.)  DA Form 3425-R - Medical Fitness Statement

  • The Medical Fitness Statement can be completed at the University Health Center for $25.  Call (805)756-1211 to schedule an appointment.

Contracting Forms

1.)  DD 2005 - Privacy Act for Health Records

3.)  SF 1199 - Direct Deposit Request

4.)  Form W-4 - Taxes

5.)  SGLV-8286 - Servicemen's Group Life Insurance

6.)  DD 93 - Emergency Data

7.)  *NGB 549-1 (ARNG) or DA 4824-R (USAR) - SMP Agreement

8.)  DA 597 (Non-Scholarship) or DA 597-3 (Scholarship) - ROTC Cadet Contract

9.)  DD Form 4 - Armed Forces Enlistment Document

* If required

Related Content

Upcoming Events

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    Week of Welcome

    13-17 October

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    Fall Joint FTX

    13-15 October

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    Ranger Challenge Competition

    27-29 October

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    Halloween Run

    30 October

Got Questions?

Contact Mr. Harris at 805.756.7690 (Office), 805.258.3357 (Mobile), or via email at kharri19@calpoly.edu

Request Info Online

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