INSTRUCTIONS TO COMPLETE THE UPR FORM 89-R THE FORM MUST BE COMPLETED IN PENCIL IMMEDIATELY UPON ENROLLMENT OF A CADET BY NEATLY PRINTING THE REQUIRED INFORMATION IN ENGLISH. ALL ITEMS WILL BE ANSWERED (USE N/A OR NONE WHERE APPLICABLE). UPON COMPLETION THE ORIGINAL FORM WILL BE FORWARDED TO THE ROO OR CADET MANAGEMENT BRANCH WITHIN FIVE WORKING DAYS OF COMPLETION FOR PROPER ENTRY OF THE DATA IN CCIMS. OICs, APMSs AND NCOIC WILL RETAIN A COPY OF THE COMPLETED FORM FOR THEIR RECORDS. DATES: All Dates must be entered in the Month/Day/Year Example: 12/30/2007 Format Items 1, 2 & 2a - Self Explanatory. SEE NOTE 1 Item 3 (School ID): Enter the candidate s school student ID number. Items 4 & 4a Self Explanatory. Item 5 (Permanent Address): Enter in English Format the candidate s home address using one of the following examples: HC-5 Muñoz Rivera Street, Urb. San Fernando, San Juan, PR 00915; 345 Ruiz Rivera Street, Caguas, PR 00724; or KM 3.5 Route 66, Barrio Botijas, Trujillo Alto, PR 00760. Item 6 - Self Explanatory. Item 7 Self Explanatory. Item 8 (Mail Address): Enter in English Format the candidate s mail address using one of the following examples: PO Box 53, Loiza Station, San Juan, PR 00906-5306; HC-02 Box 1475, Guaynabo, PR 00979-1475; or PMB-130 35 Juan A. Sierra Street, Carolina, PR 00987-5375. (If the Permanent Address and Mail Address are the same enter (see item #5). Items 9 & 10 - Self Explanatory. SEE NOTE 1 Item 11 (For appropriate entry see Other information and notes. Items 12 thru 15 - Self Explanatory. Item 16: (Marital Status): Enter S, M, D, or W as applicable. Item 17 Dependents): Enter the number of dependents including spouse. Item 18: (Race/Ethnic Group): Enter one of the following: If the candidate was born in Puerto Rico of White complexion enter C-4. If the candidate was born in Puerto Rico of Black complexion enter N-4. If the candidate is of Mexican descent of White complexion enter C-6. If the candidate is of Mexican descent of Black complexion enter N-6. If the candidate is Cuban American of White complexion enter C-9. UPR Form 89-1-R, 8 Jul 09, Previous Editions are obsolete Page l of 3
INSTRUCTIONS TO COMPLETE THE UPR FORM 89-R (CONTINUED) If the candidate is Cuban American of Black complexion enter N-9. If the candidate was born in Latin America of White complexion enter C-S. If the candidate was born in Latin America of Black complexion enter N-S. If the candidate was born of other Hispanic descent of White complexion enter C- 1. If the candidate was born of other Hispanic descent of Black complexion enter N- 1. Item 19 - Self Explanatory. Item 20 (Hair Color): Enter one of the following as applicable: BLD=Blond; BRN=Brown; BLK=Black; GRY=Grey or RED=Red Item 21 (Eyes Color): Enter one of the following as applicable: BLU=Blue BRN=Brown; BLK=Black; GRN=Green; GRY= Grey or HZL=Hazel Items 22 & 23 - Self Explanatory. Item 24 (School of Attendance): Enter the name of the University or College the candidate is enrolled and attending. Item 24a Self Explanatory. Item 25 (Academic Major): Enter the candidate s Academic Major. Item 26 (Academic Class): Enter the candidate s Academic Class as determined by his/her Academic Institution (e.g. Freshman, Sophomore, Junior, Senior or Graduate, etc.). Item 27 (MSL Class): Enter the MSL Class (MSL I, II, III, or IV) the candidate is or will be enrolled. Item 28 (Projected Graduation Date): Enter the candidate s graduation date aligned with the ROTC Program completion date (e.g. 05/30/2010; 12/30/2010, 05/30/2011, 02/28/2012, etc.) SEE NOTE 2. Item 29 (Projected Commission Date): Leave blank. Date will be determined by the PMS. Item 30 - Self Explanatory Item 3l enter S or Q as applicable. Items 32 thru 36 Self Explanatory. Item 37 (Scholarship): Complete only if the candidate is a ROTC Scholarship recipient. Items 38 thru 42 Self Explanatory. UPR Form 89-1-R, 8 Jul 09, Previous Editions are obsolete Page 2 of 3
INSTRUCTIONS TO COMPLETE THE UPR FORM 89-R (CONTINUED) Item 43 (Military Service): Enter information from the DD Form 214 blocks 12 (a thru d, 24 and 27) as applicable. Items 44 thru 47 Self Explanatory. Other related information: Item 11 (Religious Preferences): Enter one the following: Assemblies of God Evangelical Covenant Nazarene Baptist Friends (Quaker) Orthodox Buddhist Jehovah s Witnesses Pentecostal Christian Jewish Presbyterian Church of Christ Latter Day Saints Protestant Church of God Lutheran Seventh Day Adventist Disciples of Christ Methodist Roman Catholic Episcopal Muslim No Preference Item 39 (Officer Producing Programs) are: US Army ROTC US Air Force ROTC US Navy ROTC US Marine Corps ROTC Officer's Candidate School (OCS) Item 41 (Military Academies) are: US Army Military Academy, West Point US Navy Academy, Annapolis US Air Force Academy, Colorado Springs US Marine Corps Academy US Coast Guard Academy NOTES: Note 1: The Cadet s Name (Item 1); SSN (Item 2); DOB (Item 9) and POB (Item 10) will be entered and verified by the CADRE in Charge using the person s Birth Certificate and Social Security Card. The Cadet s Selective Service Number (Item 2a) will be entered and verified using the person s Selective Service Registration Card. Note 2: The Projected Graduation Date (Item 28) must be computed using the corresponding MSL Class completion date therefore indicating ROTC and Academic alignment: Examples MS I = 4 years (05/30/2013) M; MS II = 3 years (05/30/2012) and MS III = 2 years (05/30/2011). Note 3: CADRE PERSONNEL IN CHARGE WILL PLACE HIS/HER LAST NAME AND INITIALS IN THE TOP RIGHT HAND CORNER ATTESTING THAT THEY HAVE VERIFIED THE FORM FOR ACCURACY AND PROPER COMPLETION OF THE INFORMATION CONTAINED THEREIN IN ACCORDANCE WITH THIS INSTRUCTIONS. UPR Form 89-1-R, 8 Jul 09, Previous Editions are obsolete Page 3 of 3
1. NAME: CADRE LAST NAME & INITIALS: PERSONAL INFORMATION SHEET TO BE USED IN THE PREPARATION OF CC FORM 139-R DATE: ROTC CAMPUS: Father s Last Name Mother s Last Name First Name Middle Name 2. SOCIAL SECURITY #: 2a. SELECTIVE SERVICE #: 3. SCHOOL ID: (Males Only) 4. AKO MAIL ADD: 4a. EMAIL ADD: 5. PERMANENT ADDRESS: 6. HOME PHONE #: (KM #, HM #, Route #, Barrio, or House Number, Street Name or Number, Urbanization, Town, & State) 7. CELLULAR PHONE #: 8. MAIL ADDRESS: 9. DATE OF BIRTH: 10. PLACE OF BIRTH: 11. RELIGIOUS PREFERENCE: 12. BLOOD TYPE: 13. SEX: 14. HEIGHT: 15. WEIGHT: 16. MARITAL STATUS: 17. NUMBER OF DEPENDENTS: 18. RACE/ETHNIC GROUP: 19. CITIZENSHIP: 20. HAIR COLOR: 21. EYES COLOR: 22. DO YOU HAVE ANY CONDITION THAT COULD INTERFERE WITH YOU PARTICIPATING IN A NORMAL COLLEGE PHYSICAL EDUCATION COURSE? YES: NO: IF YES EXPLAIN: 22a. HAVE YOU EVER RECEIVED MEDICAL DISABILITY PAYMENTS FROM ANY SOURCE? YES: NO: IF YES EXPLAIN: 23. NEXT OF KIN: NAME, ADDRESS, RELATIONSHIP AND TELEPHONE NUMBER OF PERSON DESIGNATED AS NEXT OF KIN: 24. SCHOOL OF ATTENDANCE: 24a. COLLEGE PROGRAM: BACHELORS DEGREE: MASTER DEGREE: 25. ACADEMIC MAJOR: 26. ACADEMIC CLASS: 27. MSL CLASS: 28. PROJECTED GRADUATION DATE: 29. PROJECTED COMMISSION DATE: 30. ACADEMIC MINOR: 31.STUDY PROGRAM: SEMESTER (S)/QUARTER (Q) 32. CREDITS REQUIRED FOR DEGREE: 33. CREDITS TOWARD DEGREE: 34. COLLEGE CGPA: 35. OTHER COLLEGES ATTENDED: 35a. YEARS ATTENDED: 36. HIGH SCHOOL ATTENDED: 36a. HIGH SCHOOL ADDRESS: 36b. GRADUATION YEAR: 37. ROTC SCHOLARSHIP RECEPIENT? YES: NO: IF YES WHAT TYPE? 38. JROTC EXPERIENCE: 39. ARE YOU CURRENTLY IN THE ARMED FORCES: YES: NO: 39a. IF YES WHICH BRANCH? 39b. UNIT ASSIGNED: 39c. UNIT ADDRESS: 40. HAVE YOU EVER BEEN ENROLLED IN AN OFFICER PRODUCING PROGRAM? YES: NO: 41. WERE YOU EVER DISENROLLED FROM THE ARMY ROTC PROGRAM? YES: NO: 42. WERE YOU EVER ENROLLED IN A SERVICE ACADEMY? YES: NO: WHICH? 43. WERE YOU EVER DISCHARGED FROM THE ARMED FORCES OF THE US? YES: NO: 43a. IF YES WHAT TYPE OF DISCHARGE? 43b. IF YES WHAT WAS THE RE CODE?: 43c. MONTHS AND DAYS OF ACTIVE SERVICE: MONTHS: DAYS: 43d. HAVE YOU EVER BEEN DISCHARGED FOR MEDICAL REASONS? YES: NO: 43e. IF YES EXPLAIN: 44. HAVE YOU EVER BEEN INDICTED OR SUMMONED INTO ANY COURT CIVILIAN OR MILITARY? YES: NO: 44a. IF YES EXPLAIN: 45. HAVE YOU RECEIVED ANY TRAFFIC VIOLATION TICKETS OF $250.00 OR MORE? YES: NO: 45a. IF YES EXPLAIN: 46. HAVE YOU EVER USED ANY ILLEGAL SUBSTANCE OR DRUGS? YES: NO: 46a. IF YES EXPLAIN: 47. ARE YOU A CONSCIENTIOUS OBJECTOR? YES: NO: UPR Form 89-R, 8 Jul 09 Previous Editions are obsolete Page 1 of 2
DATA REQUIRED BY THE PRIVACY ACT OF 1974 Authority: 10 USC 2101, 2103, 2104, 2107, 2111, and 5 USC 301. Principal Purposes: To obtain personal data in order to determine eligibility for enrollment and serve as a source document for cadet s service record throughout participation in the ROTC Program. Provides data for the preparation of the Cadet s Enrollment Record (CC Form 139-R) and administration of the ROTC student commencing with application for enrollment into the ROTC Program. Routine Uses: To verify eligibility to participate in the ROTC Program; to provide information on addresses and telephone numbers for use in the event of death, injury, illness or unauthorized absence while participating in ROTC activities; to facilitate contact with complete information with a cadet during other than normal training periods; to make a matter of record the information provided by the cadet. Disclosure: Disclosure is voluntary. However, failure to provide complete information and provide responses will suspend the enrollment process into the ROTC Program. UPR Form 89-R, 8 Jul 09 Previous Editions are obsolete Page 2 of 2