The Office of Madeleine Dean

U.S. Service Academy Nomination Form

Full Name: 

Date of Birth:
Social Security #: 

Street Address: 
City, State Zip Code: ,

Home Telephone #: 

Email:

Gender:
U.S. Citizen:
If not, list your country of citizenship:

Parents/Guardians:

Education Information

Name of High School:
High School Street Address:
City, State, Zip Code: ,

GPA:
Class Size:
Rank:
Graduation Date:

SAT SCORES

Math:
Writing:
Critical Reading:
Composite:

ACT

English:
Math:
Reading:
Science:
Composite:

Academy Information

Number 1-4 the academies in order of preference:

U.S. Air Force Academy:
U.S. Merchant Marine Academy:
U.S. Military Academy:
U.S. Naval Academy:

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?:

Additional Information

Name of "hometown" Newspaper:

Is it okay to use your name in a press release after receiving a nomination or appointment?

**NOTE:

Please include a list of your extra curricular activities and leadership responsibilities.

APPLICATION AGREEMENT:

Please read the following paragraph before signing the application, as your signature indicates your agreement with the following statements. If you do not include your signature, your application will not be considered for nomination:

It is my sincere desire to attend a U.S. Service Academy, and I intend to pursue a vigorous academic course of study if appointed. I understand that attending a service academy also requires a minimum of five years of military service following graduation, and I fully commit to this responsibility. I am a U.S. Citizen, or will be by July 1 of the year I will attend the Academy. I will be at least 17 years, but not yet 23 years of age, on July 1 of the year I attend the Academy. I am not married. I am not pregnant, nor do I have any child support obligations. I am a legal resident of the 4th Congressional District of Pennsylvania.

I certify that the information I have provided in the application packet is accurate. Any changes to this information will be reported immediately. Additionally, I understand that I will not be considered for a nomination if the required documents are incomplete or are not postmarked by the first Monday in November of the current year.

Signature: ___________________________________

Date:_______________________________________

Print, and then mail or fax your request to: