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JSU Army ROTC Interest Form 

Contact Us!

4th Floor, Dollye M. E. Robinson Building

1400 John R. Lynch Street
PO Box 17569
Jackson, MS 39217-0369

(601) 979-8600


For specific questions, please find contact information on our Faculty/Staff page.

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On this page are all the forms that you need to enroll in and contract with the Jackson State University Army ROTC program. Click on a link to download the appropriate form. The forms are in .xls (Microsoft Excel Spreadsheet), .pdf (Adobe Acrobat Document), .doc (Microsoft Word Document), which can be opened with software freely available on the Internet, such as Open Office and Adobe Acrobat.

Department of Defense Forms

DD Form 4/1, Enlistment/Reenlistment Document for the Armed Forces of the United States
DD Form 93, Record of Emergency Data
DD Form 369, Police Record Check
DD Form 2005, Privacy Act Statement – Health Care Records
DD Form 2058, State of Legal Residence Certificate
DD Form 2351, DoDMERB Report of Medical Examination
DD Form 2492, DoDMERB Report of Medical History

Department of the Army Forms

DA Form 597, Army Senior Reserve Officer Training Corps (ROTC) Non-Scholarship Contract
DA Form 597-1, Acknowledgement of Understanding, Non-Scholarship Two Year Program
DA Form 597-3, Army Senior Reserve Officer Training Corps (ROTC) Scholarship Contract
DA Form 705, Army Physical Fitness Test Scorecard
DA Form 4824-R, Addendum to Certificate and Acknowledgement of Service Requirements for all US Army Reserve Personnel Applying for Participation in ROTC SMP

Cadet Command Forms

CC Form 104-R, Planned Academic Worksheet
CC Form 132-R, Statement of Understanding (Dependency)
CC Form 136-R, Briefing on Government Sponsored Benefits for ROTC Cadets
CC Form 137-R, Authorization/Declination for Access to Student Records
CC Form 139-R, Cadet Enrollment Record
CC Form 167-R, Scholarship Acceptance/Declination Statement and PMS Validation
CC Form 202-R, GRFD Non-Scholarship Cadet Contract Endorsement
CC Form 203-R, GRFD Scholarship Cadet Contract Endorsement
CC Form 204-R, Revocation of GRFD Scholarship Cadet Contract Endorsement
CC Form 226-R, Request for Conversion to Guaranteed Reserve Forces Duty (GRFD) or Dedicated Army National Guard (ARNG) Scholarship
CC Form 227-R, Request for Reserve Forces Duty (GRFD) Control Number.

NGB Forms

NGB Form 594-1, Annex to DD Form 4/DA Form 4836 – SMP Agreement ARNG
NGB Form 5435-1-R, Supplemental to DD Form 4 – Statement of Understanding

Miscellaneous Forms

SGLV 8296, Serviceman’s Group Life Insurance Election and Certificate
SF 86, Worksheet, Electronic Personnel Security Questionnaire
SF 1199A, Direct Deposit Sign Up Form (with “VOIDED” check attached)
W-4, Employee’s Withholding Allowance Certificate

Other Forms You Must Provide To Contract

Birth Certificate, State Issued (or Naturalization Certificate, if applicable)
Citizenship, Proof of
Dentist Information
Shot Record, Current
SMP Memo
Transcripts, official from all high schools and/or colleges attended
The following information: Blood type, hair color, eye color, religious preference, AKO e-mail address (if applicable)