Service Academy Nominations Form

Please review the entire application before proceeding with the online application.  It is highly recommended to draft your essay response in a word processing program -- then cut and paste the essay into the appropriate box in the application form below.

This application and the Service Academy Checklist must be completed before we can schedule an interview with the 19th Congressional District Service Academy Selection Board.  Please note that all information will be verified.

Please complete the online application and submit the form electronically. For our records, my office also requests a paper copy of the application. Please, print, sign and mail the form to my Modesto District Office at 3509 Coffee Road, Suite D3, Modesto, CA 95355. If there is a question regarding the application please contact Donna Dami in my Modesto Office. Thank you for contacting me regarding a nomination to our nation's service academies and I wish you the best of luck.

Finally, if you have any questions or concerns please do not hesitate to contact my Modesto Office at (209) 579-5458 for help.

Personal Information

Name (Last, First, Middle):
Common Name Used:
Social Security Number:
Legal Home Address:
Current Address:
(Use only if different from above)
Phone:
Email Address:
Date of Birth:
Place of Birth:
Age:
Height:
Weight:
Color of Eyes:
Color of Hair:
Do you wear glasses?
Do you wear contacts?
Marital Status:
United States Citizen?
(Note: You must be a United States citizen before entrance into any military academy.)

Academy Ranking

Please designate academy or academies for which you are applying. Rank each according to preference. First, Second, etc.

Air Force (Colorado Springs):
Army (West Point):
Navy (Annapolis):
Merchant Marines (Kings Point):

Education

Name of High School and City:
Date of Graduation:
High School GPA:
High School Class Rank: of
College Prep School GPA:
(if applicable)
College Prep School Class Rank:
(if applicable)		 of
SAT Scores --
Math:
Verbal:
Date Taken:
ACT Scores --
Math:
Verbal:
Date Taken:

Courses Taken in the Following Subjects

Name of College and City (if applicable):

College

Math:

English:

Science:

High School

Senior Year
Math:

English:

Science:

Junior Year
Math:

English:

Science:

Sophomore Year
Math:

English:

Science:

Freshman Year
Math:

English:

Science:

Family Information

Father's Name:
Occupation:
Mother's Name:
Occupation:
Did your father or mother serve in the armed forces?
If you answered "YES" to the previous question, please provide the following information.
What branch of the military did your father serve?
If he retired, what was his retirement rank?
What branch of the military did your mother serve?
If she retired, what was her retirement rank?

Academy Information

Have you made any previous academy applications?
If "YES", where?
Have you ever taken any academy examination?
If "YES", what were the results?
Have you contacted the academy to apply or to take any candidate examinations?

Extracurricular Activities (Grade School - High School - College)

School Activities:
Include Group or Club name, Offices Held, Year and any other information you deem important.
(i.e. Boy's State, Girl's State, Class Officer, Science Club, Eagle Scout, Boy/Girl Scout, Nat'l Honors, Key Club, School Band/Chorus, Jr. ROTC, Student Government, School Paper/Yearbook)

Community Activities:
Include Group or Club name, Offices Held, Year and any other information you deem important.

Athletic Activities:
Please Include Sport / Activity, Varsity Letters, Year and any other information you deem important.

Work Experience

Include Employer, Supervisor Name, Your Job Title, Your Duties, Hours Per Week, Length of Employment and any other information you deem important.

Nomination Essays

Nominee selection is based on academics, physical aptitude, medical fitness, character and leadership potential. Please write a paragraph describing your character and leadership ability.

Please explain why you desire to become a Cadet or Midshipman.

Submitting this application signifies that all the information you have provided is accurate to the best of your knowledge.