FOR OFFICIAL USE ONLY (When filled in)

CERTIFICATION OF INVOLVEMENTS WITH CIVIL, MILITARY OR SCHOOLAUTHORITIES/LAW ENFORCEMENT OFFICIALS

I. STATEMENT TO THE APPLICANT/CADET

A. The Detachment Commander must know if you have ever been arrested, convicted, involved with law enforcement officials or authorities for him/her to

determine if you meet the character requirements for membership in Air Force ROTC. It is necessary for you to report any involvement with civil, military, or school authorities/law enforcement officials regardless of its insignificance , disposition, or finding on the certification provided below. Include traffic violations and any incidents which resulted in your being judged a juvenile offender. A finding of not guilty or advice by an attorney, court official, or

anyone else to consider your record as clear does not constitute authority to leave the involvement off of the certification.

B. In the future, you must report any civil involvements to the Detachment Commander or his/her designated representatives within 72 hoursoccurrence. If such incidents occur during a period of leave from the institution (e.g., student teaching or foreign study), attendance at Field Training, or during normal vacation periods, the 72-hour time limit will apply effective with the official date of your return to the institution.

C. Concealing or failing to report an involvement with civil, military, or school authorities/law enforcement officials, giving false information or claimingsubsequent to initial certification that you were unaware of the contents of this document may result in elimination from consideration for membership

in the Air Force ROTC program; or, if already a member, may result in your discontinuance from the Air Force ROTC program. The information reported

on this certification form will be treated as confidential matter, subject to the provisions of the Privacy Act of 1974 and the Freedom of Information Act.

CERTIFICATE

CERTIFY THAT THE INFORMATION CONTAINED IN THE FOLLOWING CERTI-I,FICATIONS INCLUDES ALL ARRESTS, DETENTIONS, CONVICTIONS, INVOLVEMENTS, ETC., THAT I HAVE HAD WITH CIVIL, MILITARY (INCLUDING

ART. 15S), OR SCHOOL AUTHORITIES/LAW ENFORCEMENT OFFICIALS REGARDLESS OF DISPOSITION OR SEEMING INSIGNIFICANCE. THE LISTS

ARE COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

II. CERTIFICATION I

TYPE OF INVOLVEMENT / ORIGINAL

CITATION

DATE OF

INVOLVEMENT

NAME AND ADDRESS OF ARRESTING

AUTHORITY/COURT

DISPOSITION/FINDING

AND SENTENCE

WERE YOU DETAINED, CONFINED,

OR PLACED ON PROBATION FOR

ANY OF THE ABOVE?

WAS THE USE OF DRUGS OR

ALCOHOL CITED?NO ACTION REQUIRED CORROBORATION REQUESTED

WAIVER GRANTED CORROBORATION RECEIVEDYES NO YES NO

WAIVER DENIEDSIGNATURE OF CADET DATE REQUEST FOR WAIVER FORWARDED

TO AFROTC/RRFP

APPROVED DISAPPROVED

REMARKS/COUNSELING

SIGNATURE OF AUTHORIZED REPRESENTATIVE GRADE DATE

PREVIOUS EDITIONS ARE OBSOLETE.AFROTC FORM 35, 20100719

ACTION

Cadet has been counseled that his/her conduct will be closely monitored and any future involvements with authorities may result in disenrollment

investigation/dismissal. Cadet's initials of acknowledgement: ________

following its

DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)REPORT OF MEDICAL HISTORY

(This information is for official and medically confidential use only and will not be released to unauthorized persons.)

Mark each item "Yes" or "No". EVERY QUESTION MUST BE ANSWERED, OR PROCESSING DELAYS WILL OCCUR. Every "Yes" must beexplained in Block 83, REMARKS, on the back of the form. Mark and explain each item to the best of your ability. Be perfectly honest! Your medical records may berequested to clarify your medical history.

7. HAVE YOU EVER OR DO YOU NOW USE ANY OF THE FOLLOWING:YES NO

YES NO

Amphetamines

Barbiturates

Cocaine

Narcotic Drugs

HAVE YOU EVER HAD OR DO YOU NOW HAVE:

DoD Exception to SF93 approved by GSA/IRMS (8-91)

OMB No. 0704-0396OMB approval expiresNov 30, 2009

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034EDGERTON DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.

PRIVACY ACT STATEMENTAUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.

PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States Service Academy,Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences (USUHS).

ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their Academies.

DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy. Use of the SocialSecurity Number (SSN) is used for positive identification of records.

1. NAME (Last, First, Middle Initial) 2. SOCIAL SECURITY NUMBER 3. TELEPHONE NO. (Include area code)

4. PURPOSE OF EXAMINATION 5. EXAMINATION FACILITY OR EXAMINER AND ADDRESS (Include ZIP Code) 6. DATE OF EXAMINATION (YYYYMMDD)

DO YOUYES NO

Chemical Inhalants

Hallucinogens

Marijuana

9. Wear contact lenses or corneal eye retainers (If Yes, complete 9a.)

10. HAVE YOU EVER HAD YOUR VISION IMPROVED BY METHODS OTHER THAN STATED IN QUESTIONS 8 OR 9?

8. Wear glasses9a. If you wear contact lenses, how many days have they been removed prior to this examination?

Less than 3

Type lens:

3 - 20

Hard

21 or over

Soft

YES NO

11. Eye trouble (exclude glasses, contact lenses)

12. Have fluctuating vision or double vision

13. Have any allergies

14. Take any medications regularly

15. Stutter or stammer

16. Frequent, severe, or migraine headaches

17. Fainting or dizzy spells

18. Periods of unconsciousness

19. Head injury or skull fracture

20. Epilepsy, seizures or convulsions

21. Loss of memory (amnesia)

22. Depression, anxiety, excessive worry, or

40. Gallbladder trouble or gallstones

41. Hepatitis (yellow jaundice)

42. Hemorrhoids or rectal disease

43. Black or bloody stools

44. Frequent or painful urination

45. Bed wetting after age 12

46. Blood, protein, or sugar in urine

47. History of diabetes

48. Kidney stone

49. Hernia or rupture

50. Any bone or joint problem, injuries, surgery

66. Sleepwalking episodes after age 12

67. Easily fatigued

68. Motion sickness (car, train, sea, or air)

69. X-ray or other radiation therapy

70. Sensitivity to chemicals, dust, sunlight, etc.

71. Learning disabilities or speech problems

YES NO YES NO

nervousness

23. Any mental condition or illness

24. Frequent trouble sleeping

25. Hearing loss

26. Ear, nose, or throat trouble

27. Sinusitis or sinus trouble

28. Hay fever or allergic rhinitis

29. Tooth/gum trouble, or current orthodontics

30. Thyroid trouble

31. Chronic cough or lung disease

32. Asthma or wheezing

33. Unusual shortness of breath

34. Pain or pressure in chest

35. Palpitation or pounding heart

36. Heart trouble or heart murmur

37. High blood pressure

38. Coughed up or vomited blood

39. Stomach, liver, or intestinal trouble

or medical treatment

51. Steel pins, plates, or staples in any bones

52. Wear a bone or joint brace or support

53. Back pain or trouble

54. Paralysis or weakness

55. Foot trouble/use orthotics

56. Rheumatic fever

57. Tuberculosis or positive TB test

58. Sexually transmitted disease (syphilis, gonorrhea, herpes)

59. Skin conditions such as acne, psoriasis, hand or foot rashes, eczema, or dry skin

60. Adverse reaction to vaccines, drugs, medicines, foods, insect bites or stings

61. Eating disorder

62. Recent gain or loss of weight

63. Excessive bleeding or easy bruising

64. Tumor, growth, cyst, or cancer

65. Considered or attempted suicide

YES NO HAVE YOU EVER

72. Been refused employment or been unable to hold a job or stay in school because of:

a. Inability to perform certain movements?

b. Inability to assume certain positions?

c. Other medical reasons?

73. Been rejected for or discharged from military service because of physical, mental or other reasons?

74. Been denied or rated up for life insurance?

75. Received or applied for pension or compensation for existing disability?

76. Had or been advised to have, any surgical operations?

77. Consulted, or been treated by clinics, hospitals, physicians, healers, or other practitioners for other than minor illnesses?

78. Had any injury or illness other than those already noted?

YES NO FEMALES ONLY (Complete Items 79 - 82)

79. Been treated for a female disorder, painful periods, or cramps

80. Had a change in menstrual pattern

81. Are you now pregnant?

82. Date of last menstrual period (YYYYMMDD)

DD FORM 2492, MAR 2008 PREVIOUS EDITION IS OBSOLETE.

Alcohol (Amount,frequency, treatment,if any)

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gatheringand 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155(0704-0396). 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 notdisplay a currently valid OMB control number.

Adobe Professional 7.0

84. CERTIFICATION. I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the physicians, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service.

TYPED OR PRINTED NAME OF EXAMINEE/APPLICANT SIGNATURE OF EXAMINEE/APPLICANT

TYPED OR PRINTED NAME OF EXAMINER DATE SIGNED(YYYYMMDD)

SIGNATURE OF EXAMINER87. NUMBER OF ATTACHED SHEETS

85. EXAMINER'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA. Examiner shall comment on all "Yes" and blank answers, indicating the item number before each comment. Develop by interview any additional medical history deemed important, and record significant findings here. If additional space is required, continue on a separate sheet and attach to this form.

83. REMARKS. Applicant use only. Every "yes" response in items 7 through 81 must be explained in the space provided. Give specific dates and details including names of physicians and hospitals or clinics and the current status of the condition. If additional space is required, continue on a separate sheet and attach to this form.

DD FORM 2492 (BACK), MAR 2008

DATE SIGNED(YYYYMMDD)

86. EXAMINER

292 AFROTCI36-2011 EFFECTIVE 1 JULY 2015

Attachment 11

DRUG DEMAND REDUCTION PROGRAM MOU

Figure A11.1. Drug Demand Reduction Program MOU.

DEPARTMENT OF THE AIR FORCE AIR UNIVERSITY (AETC)

MEMORANDUM OF UNDERSTANDING FOR DRUG TESTING POLICY

FOR CADETS PARTICIPATING IN SENIOR RESERVE OFFICER TRAINING CORPS (SROTC)

By direction of the Secretary of the Air Force, I understand as an Air Force ROTC cadet participating in a SROTC program, I will be subject to random urinalysis drug testing. I understand that if I am randomly selected, I must provide the requested sample within the specified time limits. I understand failure to report for a mandatory urinalysis test will be considered an Unauthorized Absence (UA) and will result in individual command-directed screening. I understand that any individual refusing to submit a urinalysis sample or testing positive on a urinalysis test will be processed for disenrollment or dismissal from Air Force ROTC or specific officer commissioning program. ________________________________________ ____________________________________________ Cadet Signature and Date Parent/Guardian Signature and Date (Only for applicants under legal age of majority. Must be notarized if not signed in presence of detachment personnel) ____________________________________ Printed Name and Signature Witness (or Notary) and Date

Release of Liability Statement

I hereby release from liability all officials of the United States Air Force or their contractors for

their acts performed in good faith and without malice in connection with evaluation for action

concerning my application and my credentials and qualifications. I hereby release from liability

any and all individuals and organizations who in good faith and without malice provide any and

all information to officials of the United States Air Force, including medical facility officers or

authorized medical staff representatives, concerning my professional practice, competence,

ethics, character, and other qualifications for staff appointment and clinical privileges, and I

hereby consent to the release of any and all such information.

_______________________________________

Applicant Signature / Date

ANSWER THE FOLLOWING QUESTIONS (Check the applicable blocks. If yes, explain on reverse.)

APPLICATION FOR AFROTC MEMBERSHIP OMB No. 0701-0105Expires 20070531(Please read Privacy Act Statement on reverse before completing this form.)

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searchingexisting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding thisburden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, WashingtonHeadquarters Services, Directorate for Information Operations and Reports, (0701-0105), 1215 Jefferson Davis Highway, Suite 1204, Arlington, Virginia 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with acollection of information if it does not display a current valid OMB control number. Please DO NOT RETURN your form to the above address. Returncompleted form to your AFROTC detachment.

GENERAL MILITARY COURSE/PROFESSIONAL OFFICER COURSE/COLLEGE SCHOLARSHIP PROGRAM APPLICANT DATAI.NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER DATE OF BIRTH GENDER

FEMALE MALE

ETHNIC GROUPAMERICAN INDIAN ORALASKAN NATIVE

ASIAN HAWAIIAN BLACK, NOT OFHISPANIC ORIGIN

WHITE, NOT OFHISPANIC ORIGIN

DECLINE TO RESPONDHISPANIC

MARITAL STATUS NUMBER OF DEPENDENTSPLACE OF BIRTH (City/State) MARRIED SINGLE DIVORCED

COLLEGE/UNIVERSITY (Include Student ID Number if different from SSN) PROJECTED GRADUATION DATE ACADEMIC MAJOR

PERMANENT MAILING ADDRESS (Street, City, State, ZIP Code, andTelephone Number and E-mail Address)

IN CASE OF EMERGENCY CONTACT

TELEPHONE NUMBER EMERGENCY CONTACT (Include Area Code)

BACKGROUND EXPERIENCE

CURRENT MAILING ADDRESS (Dorm, Room, Telephone Number, Street, City, JUNIOR ROTC CIVIL AIR PATROL AWARDSEAGLE SCOUTState, and ZIP Code)

NONE 3-YEAR YESYES NO

NO1-YEAR 4-YEAR MITCHELL

2-YEAR EARHARTSELECTIVE SERVICE NUMBER (Males Only)

SPAATZBRANCH OF SERVICE:

MILITARY SERVICE OF PARENT OR GUARDIAN CURRENT STATUS OF PARENT OR GUARDIANYEARS OF SERVICE HIGHEST GRADEAIR FORCE

ARMYMARINESNAVY

COAST GUARDMERCHANT MARINE

CIVILIAN RETIREDMILITARY

ACTIVEDUTY

YES NOAre you now or have you ever been an enlisted or warrant officer of any component of the US armed forces (i.e., Reserve, USN, USAF,USMC, USA, USCG, Merchant Marine)? If yes, complete the rest of this block.

BRANCH OF SERVICE FROM (Mo/Yr) TO (Mo/Yr) TYPE OF DISCHARGE YEARS REMAINING ONENLISTMENT

HIGHEST GRADE

YES NO1. Have you ever applied for, been enrolled, or on contract in an Officer Training Program of the US Army, USAF, USMC, USCG, USN, MerchantMarine, or preparatory schools? (If yes, indicate in remarks where and when.)

2. Are you now, or have you ever been, a commissioned officer of any component of the armed forces (including Reserve, USAF, USN, USA,USMC, USCG, Merchant Marine)?

3. Are you now, or have you ever been, an officer of the Health Services and Mental Health Administration?

4. Are you now, or have you ever been, a member of the National Oceanic Atmospheric Administration?

5. Are you a U.S. Citizen? If yes, how obtained: BIRTH NATURALIZED(If a naturalized citizen, or born outside of the U.S. of American parents, submit proof of citizenship. Reference AFROTCI 36-2011.)

6. Have you ever taken the AFOQT? (If yes, indicate in remarks section where and when.)

7. Have you ever had a physical for entry into the armed forces, Air Force ROTC, etc.? (If yes, indicate in remarks section where and when.)

8. Have you ever been denied enlistment into the armed forces?

9. Do you already have a degree (BA, BS, etc.)?

10. Are you an AFROTC Scholarship Designee? NO YES (Check one) 4-year 3-year

11. Are you a conscientious objector? (A conscientious objector is defined as: one who has or had a firm, fixed and sincere objection to participation in war in any form or to bearing of arms because of religious training or belief, which includes solely moral or ethical beliefs.)

12. Are you now or have you ever been affiliated with any organization or movement that seeks to alter our form of government byunconstitutional means, or sympathetically associated with any such organization, movement, or members thereof? (If yes, please describe.)

AFROTC FORM 20, 20060901, V1 PREVIOUS EDITIONS ARE OBSOLETE.

Per AFI 36-2011 para 4.3.2.5 and 4.3.2.6:AF Form 883, Privacy Act Statement/ DD Form 2005, Privacy Act Statement – Health Care Records copy recieved.Signature:___________________________

YES NOANSWER THE FOLLOWING QUESTIONS (CONT)13. Do you understand that participation in Air Force ROTC requires strenuous physical activity? (You will be required to obtain medicalclearance from a physician prior to program entry.)II. STATEMENT OF UNDERSTANDING

I understand that membership in the General Military Course (GMC) or attendance at Field Training (FT) does not guarantee that I will be accepted into theProfessional Officer Course (POC). I understand that if I am not on scholarship, attendance at FT does not guarantee or commit me to enter the POC.GMC scholarship cadets who attend the first AS 200 class or Leadership Laboratory incur an Active Duty Service Commitment and are liable to call toextended active duty or recoupment (which includes payback of scholarship benefits received during the AS 100 year).

SIGNATURE OF APPLICANT DATE

III. OATH OF ALLEGIANCE

swear or affirmI do solemnly that I will support and defend the Constitution of the United States against all enemies foreign or domestic; that I willbear true faith and allegiance to the same; and that I take this obligation freely, without any mental reservation or purpose of evasion.

SIGNATURE OF APPLICANT DATE

REMARKS

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 33, Appointment in Regular Component; 10 U.S.C. 103, Senior Reserve Officers’ Training Corps as implemented by AFROTCI 36-2011,Air Force Reserve Officers’ Training Corps; and E.O. 9397 (SSN). PURPOSE: To process and manage selected students for acceptance into the USAF ROTC program. ROUTINE USES: This information may be disclosed to federal, state, local or foreign law enforcement authorities for investigating or prosecuting aviolation or potential violation of law; to federal, state, or local agencies to obtain information concerning hiring or retention of an employee, issuance of a securityclearance, letting of a contract, or issuance of a license, grant or other benefit; to a federal agency in response to its request in connection with the hiring orretention of an employee, issuance of a security clearance, reporting of an investigation of an employee, letting of a contract, issuance of a license, grant, orother benefit by the requesting agency to the extent that the information is relevant and necessary to the requesting agency's decision on the matter; to acongressional office in response to their inquiry made at the request of the individual; to the Office of Management and Budget in connection with review ofprivate relief legislation as set forth in OMB Circular A-19; to foreign law enforcement, security, investigatory, or administrative authorities to comply withrequirements of international agreements and arrangements; to state and local taxing authorities in accordance with Treasury Fiscal Requirements ManualBulletin 7607; to the Office of Personnel Management (OPM) concerning information on pay and leave, benefits, retirement deductions, and other informationnecessary for OPM to carry out its functions; to NARA for records management functions; and to the Department of Justice for pending or potential litigation. DISCLOSURE: Furnishing the information is voluntary. Failure to provide requested information will hinder processing.

AFROTC FORM 20, 20060901, V1 (REVERSE)

RESTRICTIONS ON PERSONAL CONDUCT IN THE ARMED FORCES

1. Military life is fundamentally different from civilian life. The military has its own laws, rules, customs, and traditions, including numerous

restrictions on personal behavior, that would not be acceptable in civilian society. These are necessary because military units and personnel

must maintain the high standards of morale, good order, discipline, and unit cohesion that are essential for combat effectiveness.

2. The Armed Forces must be ready at all times for worldwide deployment. Military law and regulations, including the Uniform Code of Military

Justice, apply to service members at all times, both on base and off base, from the time the member enters the service until the member is

discharged or otherwise separated from the Armed Forces.

3. Members of the Armed Forces may be involuntarily separated before their term of service ends for various reasons established by law and

military regulations, such as:

a. A member may be separated for a pattern of disciplinary infractions, a pattern of misconduct, commission of a serious offense, or

civilian conviction.

b. A member who has been referred to a rehabilitation program for personal drug and alcohol abuse may be separated for failure

through inability or refusal to participate in, cooperate in, or successfully complete such a program.

c. A member may be discharged by reason of parenthood, if it is determined the member, because of parental responsibilities, is

unable to perform his or her duties satisfactorily or is unavailable for worldwide assignment or deployment.

d. A member may be separated for failure to meet service weight control standards or physical fitness standards.

e. A member may be separated for harassment of or violence against any service member.

SIGNATUREDATE OF APPLICATION NAME (Last, First, MI)

SIGNATUREDATE OF ENLISTMENT NAME (Last, First, MI)

SIGNATUREDATE OF COMMISSION NAME (Last, First, MI)

AFROTC FORM 500, 20110804 PREVIOUS EDITIONS ARE OBSOLETE.

AFROTCI36-2011 12 AUGUST 2013 Attachment 14 - AIR FORCE DEPENDENCY POLICY STATEMENT OF

UNDERSTANDING

I, , have been briefed on the Air Force policies concerning family care responsibility and family care responsibility as an AFROTC retention standard. (A family member is any person over whom I have legal or physical custody or control, or who relies primarily upon me for their care, maintenance, or support regardless of age). In particular, I understand the following: a. As a cadet in AFROTC, if I become unmarried or married (to include a common-law spouse) to a military member (including another AFROTC cadet), and become responsible for any family member incapable of self-care, I must acquire and maintain an approved Family Care Plan IAW AFI 36-2908, Family Care Plans, that will adequately cover my time in AFROTC. Additionally, I understand that upon arrival at my first duty station, I will be required to submit a revised family care plan. While in AFROTC if I am unable or unwilling to create or maintain such a family care plan, I will no longer meet AFROTC retention standards. In such a case, I would then be subject to disenrollment from AFROTC for failure to maintain military retention standards. If I am disenrolled, I will also be subject to recoupment of my scholarship benefits. b. If I am disenrolled from AFROTC after becoming a contract cadet, I am subject to call to EAD in my enlisted grade, recoupment of scholarship benefits, or release. If I have more than two (three with an approved waiver) dependents incapable of self-care, I understand I do not meet enlisted accession standards and cannot be subject to EAD in my enlisted grade and can only be subject to recoupment or release.   1st Ind, Application Cadet Signature/ Date Cadre Signature/Date 2nd Ind, Enlistment Cadet Signature/Date Cadre Signature/Date NOTE: Cadet and detachment representative must sign statement at time of application. Statement must be recertified by the cadet and detachment representative at time of enlistment.