DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD

APPLICATION FOR ADVANCED EDUCATION

Coast Guard Personnel Command (CGPC-opm-1) 2100 Second Street, S.W., Washington, D.C. 20593

PRIVACY ACT STATEMENT In accordance with 5 U.S.C. § 552a, the following information is provided when supplying personal information to the U.S. Coast Guard AUTHORITY: 14 U.S.C. § 633. PURPOSE: Factor in selection for advanced education. ROUTINE USE: Same as above. DISCLOSURE: Disclosure of the information is voluntary, but non-disclosure may result in diminished chances for selection for advanced education.

1. Provide the following informationRank/Grade: Complete Legal Name (Last, First, MI): SSN:

2. Unit Address

Street Address:

City: State: Zip Code:

Telephone Number (Include area code): Valid Until: Telephone Number (After that date):

Email Address: Fax Number: Valid Until:

3. Age: 4. Your Legal State of Residence:

5. Curriculum Choices (Use curriculum codes from page 4)

First Choice:

Second Choice:

Additional Choices (Normally only your first & second choice will be considered, unless needs of the service dictate otherwise):

6. Years of Commissioned Service: 7. OPFAC: 8. Date Reported at Present Unit:

9. Expected Rotation Date: 10. Original Date of Commission: 11. Experience Indicator:

12. Status Indicator:

CG-5651 (03/20) Page 1 of 4

CG-5651 (03/20) Page 2 of 4

13. Academic Training (Give names of all academic institutions you have attended since high school, in chronological order. Also, include correspondence courses for which you have obtained college credit. Attach additional sheets if necessary):

Institution Major & Minor FieldsDates AttendedFrom To

Degree(s) Received or Expected (BS or BA)

Date Awarded or Expected

14. Undergraduate GPA: Undergraduate Major GPA:

15. Enter the name of the standardized test required for each program to which you are applying. Include the month & year you will take or have taken it & your score.

Name of Test

Month/ Year

TakenSubject Area 1

Score/ % Rank

Subject Area 2

Score/ % Rank

Subject Area 3

Score/ % Rank

Subject Area 4

Score/ % Rank

Score/ Rank Overall

Example: GRE 05/98 Verbal

580 / 76% Quantitative

570 / 51% Analytical

660 / 83% Physics

700 / 88% N/A

/%

/%

/%

/%

/

/%

/%

/%

/%

/

/%

/%

/%

/%

/

/%

/%

/%

/%

/

/%

/%

/%

/%

/

/%

/%

/%

/%

/

16. Experience (Attach additional sheets if necessary):

Unit Primary DutiesDates

From To

CG-5651 (03/20) Page 3 of 4

22. ALL APPLICANTS: Please Read the Following & Sign

I understand the extended service obligation I incur upon reporting for postgraduate education (or specialized training). I agree not to request resignation during the source of instruction. I understand that actual assignment to a postgraduate education program (or specialized training), if selected, depends on my admission to an approved school.

(Signature) (Date)

23. Please attach a statement concerning your reasons for applying to your curriculum choices. Also address how the Coast Guard will benefit by sending you. No letters or recommendation may be included, but should include a forwarding endorsement. Forwarding endorsements shall contain a considered opinion of the applicant's interests, ability, & potential value to the service relating to the curricula requested.

24. Mail your application, all attached forms, and a self addressed Acknowledgment/Referral Card (CG-4217) or Document Receipt Card (CG-9733) to:

ATTN: Postgraduate Training Section Commander (CGPC-opm-1)

Coast Guard Personnel Command 2100 2nd Street, S.W.

Washington, D.C. 20593-0001

Remember to Include the Following:

1. Your Name & SSN on any Attached Sheets;

2. Your College Transcripts -- Highlight Required Courses for Your Curriculum Choices;

3. Required Test Results;

4. Phone Number Where you can be Reached Throughout PG Panel Session; and

5. Command Endorsement.

CG-5651 (03/20) Page 4 of 4

CURRICULUM CODES FOR ADVANCED EDUCATION (For Page 1 of Application)

Academy Instructor (Disciplines to be announced)1. USCGA/OPM-2JADV Computer Elec. Tech.2. G-SRP/OPM-2CAeronautical Engineering (Structures)3. G-SEA/OPM-2EAviation Engineering Admin. (MSIA)4. G-SEA/OPM-2EAviation Maintenance Officer Training5. G-SEA/OPM-2EAvionics Engineering6. G-SEA/OPM-2EAviation Operations Research7. G-SEA/OPM-2ECivil Engineering8. G-SEC/OPM-2DElectrical Engineering9. G-SRF/OPM-2CEnvironmental Manegement10. G-MPR/OPM-2GFinancial Management11. G-CFM/OPM-2JFire Protection/Electrical Engineering12. G-MPR/OPM-2GHazardous Materials/Industrial Hygiene13. G-MPR/OPM-2GHealth Care Admin. - Graduate14. G-WKH/OPM-2KHealth Care Admin. - Undergraduate15. G-WKH/OPM-2KHuman Resources Development (Incorporates RPA Admin, science, but not limited to RPA's)16. G-WTR/OPM-2K/GHuman Resources Development (Part time)17. G-WTR/OPM-2K/GIndustrial Management18. G-SLP/OPM-2DInformation Technology Management (ITM) (ITM is a consolidated panel)19.

G-SRF/OPM-2C/GCommunications Systems Engineering - Consolidated into ITMA.Computer Science/Systems Management - Consolidated into ITMB.Information Systems Management - Consolidated into ITMC.

Industrial Technology20. G-WTT/OPM-2B/GLaw21.

JDA.LLMB.

G-LPD/OPM-2J

Leadership Studies22. G-WTL/OPM-2JManagement of Technology (MIT)23. G-A-1/OPM-2C/DMarine Affairs/Living Marine Resources24. G-OPL/OPM-2BMarine Corps College (Command & Staff)25 G-OPD/OPM-2BMarine Engineering26. G-MPR/OPM-2GMarine Engineering Technology (MET)27. G-MPR/OPM-2GMarine Safety Industry Training Programs (Separate/distinct panels)28.

G-MPR/OPM-2GInvestigations Industry Training (IIT)A.Marine Environmental Protect Industry Training (MEPIT)B.Merchant Marine Industry Training (MMIT)C.Port Safety Industry Training (PSIT)D.

Naval Engineering29. G-SEN/OPM-2DNaval Engineering Technology30. G-SENOPM-2DNaval War College (Command & Staff)31. G-OPD/OPM-2BOcean Engineering (A civil engineering discipline)32. G-SEC/OPM-2DOceanography33. G-OPN/OPM-2GOperations Research34. G-WR-2/OPM-2J/G/EPhysician Assistant35. G-WKH/OPM-2KPublic Administration36. G-CPP/OPM-2JPublic Affairs37. G-CP/OPM-2KSloan Fellowship38. G-CPA/OPM-2Strategic Intelligence39. G-OCI/OPM-2BFlight School40. G-SEA/OPM-2E

Curriculum Codes