I am applying for the class entering the year: * Select 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Permanent Address: * Zip: *

Mailing Address:

Telephone: (home)* (work) (relative)

Date of Birth:*       Place of Birth:*

Height:      Weight:      Gender:* Male Female

Mother's Name:*		Occupation:
Father's Name:*		Occupation:

Is your uncorrected visual acuity in each eye at least 20/20?* Yes No

If No, is your corrected visual acuity in each eye at least 20/20? N/A Yes No

What is the primary language spoken in your home?*

Are you on active duty, or on reserve in the armed forces?* Yes No

If Yes, which service?

Any Dependents? Yes No Marital Status? Married Single Seperated Divorced

Are you a U.S. citizen? * Yes No
If NO contact the Field Force Member for your first choice academy

High School:*			Date of High School Graduation:*
Mailing Address:*
Telephone:*
GPA:			Class Rank: (ie. 5/1000)
PSAT:			Date:
SAT:			Date:
2nd SAT:			Date 2nd:
ACT:			Date:
ACT 2nd:			Date 2nd:
Principal:			Counselor:
College (if applicable):
Mailing Address:
Years Attended:	Hours Completed: GPA:
Telephone:			Major:

In 500 words or less, explain why you wish to attend a U.S. Service Academy.   Describe any special circumstance in your individual or family history which you wish to be considered, or any additional information not covered in the application above.

   

I have read and understood the Privacy Act Statement. The answers provided are true and correct to the best of my knowledge.  I understand that in addition to the above referenced information, I am also required to submit the following:

1. SAT and/or ACT test scores.

2. Three completed recommendation forms which must be sent directly to the Congressman's Merrillville office by the author.

If I do not submit all the necessary data by the stated deadline, I understand that I may not be given final consideration for a nomination.