NPP Application 1

NPP APPLICATION 1
Personal Information
Name (Last, First, Middle)
Phone Number
Current Mailing Address
Name of Parent/Guardian
Place of Birth
Date of Birth

MonthDayYear
Date
Address of Parent/Guardian
Are you a US Citizen?

YesNo
Gender

MaleFemale
If Naturalized, give date, place, court of jurisdiction, and certificate number.
What is your race? Mark one or more of the categories below to indicate how you identify your race.

American Indian/Alaskan NativeAsianAfrican American/BlackNative Hawaiian/Other Pacific IslanderCaucasian
Ethnic Background (Optional)

AleutChineseCubanEskimoFilipinoKoreanLatin American w/ Hispanic DescentMelanesianMexicanMicronesianOther Asian DescentOther Hispanic DescentOther Pacific Island DescentPolynesianPuerto RicanUS/Canadian Indian TribesVietnameseOtherNone
Email
example@example.com
Intended Major or Area of Study (Tier 1 or Tier 2 only)
Parent/Legal Guardian's Previous Military History

Line no. 1
Parent/Guardian Name
Branch
Rank/Rate
Status (Active/Retired)
Commissioning Source
Parent/Legal Guardian's Previous Military History

Line no. 2
Parent/Legal Guardian
Branch
Rank/Rate
Status (Activated/Retired)
Commissioning Source
Extracurricular Activities

READ CAREFULLY: Identify only those activities in which you engaged during school grades 9-12. NROTC is particularly interested in identifying activities in which an applicant has participated involving responsibility and leadership. Examples: NJROTC, Student Government, Eagle Scout, etc...
Extracurricular Activities 1
Organization
Position Held
Hours/Week
Grades of Participation

9101112
Extracurricular Activities 2
Organisation
Position Held
Hours/Week
Grades of Participation

9101112
Extracurricular Activities 3
Organization
Position Held
Hours/Week
Grades of Participation

9101112
Extracurricular Activities 4
Organization
Position Held
Hours/Week
Grades of Participation

9101112
Athletic Activities

READ CAREFULLY: Identify only those sports in which you engaged during school grades 9-12. Mark the year(s) in which you were on the varsity team. If you 'lettered' in the sport list that in the awards. Mark 'JV/Club' if you participated at this level in any year. Do not list intramural activity.
Athletic Activities 1
Sport
Position Held
Awards/Recognition
JV/Club
Grades of Participation

9101112
Athletic Activities 2
Sport
Position Held
Awards/Recognition
JV/Club
Grades of Participation

9101112
Athletic Activities 3
Sport
Position Held
Awards/Recognition
JV/Club
Grades of Participation

9101112
Athletic Activities 4
Sport
Position Held
Awards/Recognition
JV/Club
Grades of Participation

9101112
Other Activities

Attach additional sheets, if needed, to identify other activities not listed above that involve considerable responsibility and leadership. List positions held and the average number of hours devoted per week to the activity.
Employment

List in reverse chronological order beginning with the most recent, each period of full-time, part-time, or self-employment. List inclusive dates for each period. If discharged for cause from any employment, so state. Include any leadership responsibilities.
Employment 1
From

MonthDayYear
Date
To

MonthDayYear
Date
Employer Name, Address & Phone Number
Hours/Week
Type of Work Performed
Employment 2
From

MonthDayYear
Date
To

MonthDayYear
Date
Employer Name, Address & Phone Number
Hours/Week
Type of Work Performed
Employment 3
From

MonthDayYear
Date
To

MonthDayYear
Date
Employer Name, Address & Phone Number
Hours/Week
Type of Work Performed
Volunteering

READ CAREFULLY: Identify only those volunteering activities in which you engaged during school grades 9-12. List the number of hours performed per year in the box corresponding to the correct school year and volunteer activity. If other is selected, please include a brief description of your volunteer work in the remarks. Attach additional sheets if more space is needed.
Grades (Hospital/Candy Striper)

9101112
Grades (With handicapped Elderly)

9101112
Grades (Tutor/Coach Children)

9101112
Grades (Other)

9101112
Total Volunteer Hours in Grade 9
Total Volunteer Hours in Grade 10
Total Volunteer Hours in Grade 11
Total Volunteer Hours in Grade 12
Volunteer Work Remarks
Would you be willing to attend any university with a similar program resulting in a Naval Commission?

YesNo
Essay 1: Why do you want to become a Commissioned Officer through University of Maryland, Baltimore County? (400 words or less)
Essay 2: Have you experienced any adversity in your life (parents divorced, single parent family, multiple high schools, frequent moves etc.). If so, describe the circumstances and how you met the challenges. (400 words or less)
Answer the following questions. If you answer 'Yes' provide explanations on an additional sheet.
1. Have you ever applied for or signed any agreement concerning any program leading to a commission in any of the Armed Forces of the United States? (If 'Yes', list the date, place of application, program applied for and current status of application.)

YesNo
2. Have you signed an Enlistment Contract (DD Form 4) with any of the Armed Forces of the United States? (If 'Yes', list the date, place, service, and current status of enlistment.)

YesNo
3. Have you ever been arrested, detained, indicted, summoned into court, or convicted for any violation of civil or military law, including juvenile offenses and moving traffic violations? (If 'Yes', give complete description of incident, name and place of court, nature of offense, date, and disposition

YesNo
4. Are you currently awaiting trail or sentence, on probation, under suspended sentence, or under any other type of military or civilian restraint as a result of violation of law or regulation?

YesNo
5. Have you ever been known by any other name or names other than that used in this application? (If 'Yes', explain in affidavit form and submit with application, even if differences were only differences in spelling.)

YesNo
6. Do you have any moral obligations or personal convictions that will prevent you from conscientiously bearing arms and supporting and defending the constitution of the United States against all enemies, foreign and domestic?

YesNo
7. Have you ever taken any narcotic, sedative, or tranquilizer drugs other than as prescribed by a physician or dentist? (If 'Yes', attach a statement with the full circumstances, number of time used, amounts taken, period over which taken, and intent for further use.)

YesNo
8.Have you ever been arrested or convicted of trafficking illegal drugs?

YesNo
9. Have you ever used LSD, marijuana, sniffed glue or used any other hallucinogens, hypnotic, stimulants, or other known harmful or habit-forming drugs and/or chemicals? (If 'Yes', attach a statement with the full circumstances, number of times used, amounts taken, period over which taken, and intent for further use.)

YesNo
I certify that all information given by me is complete and correct to the best of my knowledge. I understand that this applicant questionnaire does not obligate me in any way, and that I may withdraw my application at any time.
Applicant Signature

Clear
Date

MonthDayYear
Date
Parent/Legal Guardian Signature

Clear
Date

MonthDayYear
Date
Medical History
Height
Weight
Date of Last Sports Physical / Private Sector Physical
Remarks
Answer the following questions. If you answer 'Yes' provide explanations in block 41
1.Eye trouble (to include vision loss, cataract, glaucoma, keratoconus, corneal ectasia, retinal detachment)?

YesNo
2.Surgery to improve vision (PRK, LASIK, LASEC, RK, intraocular lens implant, cross linking)?

YesNo
3.Color vision deficiency?

YesNo
4.Ear trouble (to include perforated ear drum, tubes in ears, or other ENT surgery)?

YesNo
5.Loss of balance or vertigo?

YesNo
6.Hearing loss or use of a hearing aid?

YesNo
7.Nose, throat, or sinus trouble (to include sinusitis, abscess, surgery on nose, sinuses or throat)?

YesNo
8.Orthodontic treatment? (if "yes", include completion or projected date of completion in block 41)

YesNo
9a. Tooth or gum trouble (excluding cavities)?

YesNo
9b. Date of last dental exam:

MonthDayYear
Date
10.Breathing trouble (to include asthma, wheezing, shortness of breath, chronic cough, use of inhaler, collapsed lung)?

YesNo
11.Cardiac trouble (to include chest pain, palpitations, heart valve problems, surgery, high or low blood pressure)?

YesNo
12.Gastrointestinal trouble (to include celiac disease, irritable bowel syndrome, ulcer, reflux, esophagitis, gallstones, hernia, orhepatitis)?

YesNo
13.Inflammatory bowel disease (to include Ulcerative colitis or Crohn's disease)?

YesNo
14a. Gynecologic trouble (including endometriosis, polycystic ovarian disease, abnormal pap smear)? (females only)

YesNo
14b. Date of last menstrual period (females only):

MonthDayYear
Date
14c. Date of Last PAP smear (females only):

MonthDayYear
Date
15.Testicular or prostate trouble? (males only)

YesNo
16.Orthopedic problems of the back or neck?

YesNo
17.Orthopedic problems of the upper extremities (fracture, dislocation, sprain, surgery)?

YesNo
18.Orthopedic problems of the lower extremities (fracture, dislocation, sprain, surgery)?

YesNo
19.Vascular trouble (Raynaud's disease, blood clot or deep venous thrombosis, high blood pressure)?

YesNo
20.Skin trouble (to include psoriasis, eczema, atopic dermatitis, severe acne)?

YesNo
21.Prescribed systemic retinoid medications (i.e.: Accutane)? (List date completed or projected completion date in block 41.)

YesNo
22.Blood disorders (anemia, thrombocytopenia, bleeding disorders, disorder of the spleen)?

YesNo
23.Allergic reaction to food, medications, insects?

YesNo
24.A positive PPD or been treated for tuberculosis?

YesNo
25.Car, train, sea, or air sickness that required prescription medication or avoidance of travel?

YesNo
26.Endocrine disorders (including diabetes, thyroid, osteoporosis)?

YesNo
27.Head injury, memory loss, amnesia?

YesNo
28.Neurologic trouble (including dizziness, fainting spell, seizure, paralysis)?

YesNo
29.Frequent or severe headaches in the past 2 years?

YesNo
30.Sleeping trouble (narcolepsy, sleepwalking, chronic insomnia, sleep apnea)?

YesNo
31.Evaluation or treatment for depressive disorder?

YesNo
32.Evaluation or treatment for anxiety disorder or panic attacks?

YesNo
33.Evaluation or treatment for eating disorders (anorexia or bulimia)?

YesNo
34.Evaluation or treatment for attention deficit hyperactivity disorder, attention deficit disorder, or learning disability?

YesNo
35.Tumor or cancer?

YesNo
36.Cold or heat injury?

YesNo
37.Rhabdomyolysis?

YesNo
38.Have you been prescribed medications in the last 12 months? (if "yes" list names, reason, and approximate dates used in Block41)?

YesNo
39.Have you EVER been hospitalized (including psychiatric)?

YesNo
40.Have you EVER been rejected or discharged for military service for any reason?

YesNo
Medical Comments
41.Explain all "Yes" answers to questions 1-40 above. Begin with the Item Number. Describe answer(s): provide date(s) of problem(s) /condition(s);provide names of Health Care Providers (HCPs), Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/ortreatment); and describe your current medical status (ongoing/resolved). Attach additional sheet(s) if necessary and sign and date each additional page.Obtain and attach copies of applicable medical evaluation and treatment records if requested.
Type a question
I certify that all medical information provided by me is complete and correct to the best of my knowledge.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

NPP APPLICATION 1

Personal Information

Parent/Legal Guardian's Previous Military History

Parent/Legal Guardian's Previous Military History

Extracurricular Activities

Extracurricular Activities 1

Extracurricular Activities 2

Extracurricular Activities 3

Extracurricular Activities 4

Athletic Activities

Athletic Activities 1

Athletic Activities 2

Athletic Activities 3

Athletic Activities 4

Other Activities

Employment

Employment 1

Employment 2

Employment 3

Volunteering

Answer the following questions. If you answer 'Yes' provide explanations on an additional sheet.

I certify that all information given by me is complete and correct to the best of my knowledge. I understand that this applicant questionnaire does not obligate me in any way, and that I may withdraw my application at any time.

Medical History

Answer the following questions. If you answer 'Yes' provide explanations in block 41

Medical Comments

I certify that all medical information provided by me is complete and correct to the best of my knowledge.