APPLICATION FOR CONGRESSIONAL NOMINATION

TO A U.S. SERVICE ACADEMY

FOURTH CONGRESSIONAL DISTRICT, INDIANA

Full Name: ___________________________________________

Address:    ___________________________________________                 PHOTO

                  ___________________________________________

County: ___________________    Phone: __________________

E-Mail Address:  ______________________________________

SS# ____________________       DOB: ____________________

U.S. Citizen______    HT  _____    WT  _____       Uncorrected Vision: __________

Father's Name: _________________________    Occupation: _________________

Address/Phone:  _____________________________________________________

Mother's Name: ________________________     Occupation: _________________

Address/Phone:    ____________________________________________________
 

TO WHICH ACADEMIES HAVE YOU APPLIED?

    AIR FORCE _____    COAST GUARD _____    MERCHANT MARINE _____

                    MILITARY _____        NAVAL _____
 

EDUCATIONAL BACKGROUND:

High School:   ______________________________________________________

GPA:    _______      Class Rank:    _______        Graduation Date:  ____________

SAT Scores:            Verbal:    _______         Math:    _______       Writing: ________

ACT Scores:          E__________    M_________    S_________    R__________

Future Test Dates (if any)  ____________________________________________

Honors Courses ____________________________________________________

 _________________________________________________________________

Foreign Languages  _________________________________________________

Athletics ___________________________________________________________

__________________________________________________________________

Student Government _________________________________________________

__________________________________________________________________

Academic/Athletic Awards _____________________________________________

__________________________________________________________________

Extracurricular Activities_______________________________________________

__________________________________________________________________

Part-time/Full-time Employment_________________________________________

__________________________________________________________________
 

CHARACTER REFERENCES:    (Non-family members who will be sending letters of recommendation to this office.)

1.    ____________________________________________

2.    ____________________________________________

3.    ____________________________________________

Have you had any legal or disciplinary problem? School suspensions/expulsions, drug or alcohol arrests, convictions, etc?

If the answer is "Yes", please explain__________________________________________________________________________________

__________________________________________________________________________________________________________________

Is there any other information about you, that if it became public, would cause disrepute to the Academy to which you seek appointment?

If the answer is "Yes," please explain___________________________________________________________________________________

______________________________________________________________________________________________________ 

PREVIOUS OR PENDING ACADEMY APPLICATIONS/NOMINATIONS:

Are you seeking a nomination from another office?  If yes, please identify the office and current status:

__________________________________________________________________

Have you previously sought a nomination?  Results?

__________________________________________________________________
 
 

Attach a 100 word essay that describes your reasons for seeking an academy nomination, and for serving your country as a commissioned officer.
 

Signature___________________________________________        Date________________________

Please initial here to authorize release of your information to ROTC programs seeking applicants for ROTC scholarships. ______________
 

(Please return application to Congressman Steve Buyer, 100 S. Main Street, Monticello, IN  47960)
 

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