Service Academy Nominations

First Name *	MI	Last Name *

* Date of Birth:

SSN (No Dashes):

* Address:

* City:

* State:

* Zip:

Gender:

* Please provide the names of your Parents/Guardians:

Home Phone Number:

Cell Phone Number:

* Email:

Education Info:

High School

Graduation Date

* Address:

* City:

* State:

* Zip:

* GPA:

Class Size:

Class Rank:

Academy Preference: Indicate your preference in numerical order. Please do not designate any academy you would not accept. Due to the competitive nature of the nomination process, you may receive a nomination to the academy of your second, third, or fourth choice.

First	Second

Third	Fourth

An appointment to the Service Academies is based on a desire by the candidate to devote a lifetime of military service and implies recognition by the appointee of an obligation to the government to devote him / herself to a military career. Are you interested in an appointment on that basis?
Yes No

EXTRACURRICULAR ACTIVITES
Remember to include:

Special awards and honors with dates.
School and outside club memberships and activities, noting leadership positions and honors received, with dates.
Employment, both after school and in summer, with dates and hours per week.
Volunteer involvement, with dates and hours per week.
School athletics (note Captain, Varsity letter, MVP, All-League, etc.) with dates.
Out-of-school recreational athletics, with dates.

Is it ok to use your name in a press release?
Yes No

Name of home town paper?

The information above is correct. I am unmarried, not pregnant; have no child support obligation; and am a legal resident of the District. On July 1st of the year of my application, I will be an U.S. Citizen, and at least 17 but not 23 years of age.