Prefix 

* First Name 

MI 

* Last Name 

Suffix 

* Address Line 1 

* City 

* State 

* Zip 

* Home Phone 

* Cell Phone 

* Email 

 

Please be sure that the email listed is one that is checked on a regular basis.  Information about interviews and other information may be communicated via e-mail.


Mailing or Temporary Address - Leave Blank if Same as Above

Address Line 1 

Address Line 2 

City 

State 

Zip 

 

* Birth Date (MM/DD/YYYY) 

 

* Social Security Number 

 

* Are you a U.S. Citizen? 



 

* Mother's Name 

 

* Father's Name 

 

 
Parents' Address - Leave Blank if Same as Above

Address Line 1 

Address Line 2 

City 

State 

Zip 

 

 
Academy Choice - Please only select an academy if you would consider accepting a nomination to said academy.
 

* 1st Choice 

 

2nd Choice 

 

3rd Choice 

 

4th Choice 

 

 
We recommend you apply for nominations from both Senate offices in addition to Congressman Himes.

* Are you also seeking a nomination from Senator Blumenthal? 



 

* Are you also seeking a nomination from Senator Murphy? 



 

 

* High School Name 

 

* Address 

 

* City 

 

* State 

 

* Zip 

 

Country 

 

* Date of Graduation 

 

* Guidance Counselor 

 

* School Phone Number 

 

 
SAT Scores

SAT Math Score 

 

SAT Verbal Score 

 

Date SAT Taken 

 

 
SAT Math Score

 

SAT Verbal Score 

 

Date SAT Taken 

 

 
ACT Scores

ACT Subject 

 

Score 

 

Date Taken 

 

 
ACT Subject

 

Score 

 

Date Taken 

 

 
AP/Honors Classes
Please list the classes you are taking/have taken this year that are Honors, AP, etc.

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
AP/Honors Subject

 

Score 

 

Semester Taken 

 


AP/Honors Subject

 

Score 

 

Semester Taken 

 


AP/Honors Subject

 

Score 

 

Semester Taken 

 


AP/Honors Subject

 

Score 

 

Semester Taken 

 


AP/Honors Subject

 

Score 

 

Semester Taken 

 


AP/Honors Subject

 

Score 

 

Semester Taken 

 

 
In the section below, please list the extracurricular, athletic, and community activities in which you participated during high school (and college).  List them in order of their importance to you and include any positions held or awards received.

Activity 

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received 

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received 

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received 

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received 

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received 

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received  

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received  

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received  

 

 
Activity

 

Years Involved 

 

Hours Per Week 

 

Offices Held and/or Awards Received  

 

 
Activity

 

Hours Per Week 

 

Years Involved 

 

Offices Held and/or Awards Received  

 

 
List any awards, honors, or special activities:

 

 

 

 

 

 

 

 

 

 

 
Community Service Experience:

 

 

 

 

 

 
Work Experience:

 

 

 

 

 

 
Family members who are Academy graduates:

 

 

 

 

 

 

In the nomination process, we hope to learn about each candidate as a whole. SAT scores, transcripts, and activities tell us only so much information about you as a person.

The following short answer and personal statement questions will help us better understand you and your motivation for attending a United States Service Academy. Please remember that there are no right or wrong answers.

Please type your response to the following short answer and personal statement as a separate document and upload them in the appropriate box.  Please make sure that your name is on the top, right hand corner of each page.

 
Short Answer Question: On the previous page, you were asked to list your activities by order of importance to you. Please tell us why you consider your top activity to be most important. What have you learned from participating in that group, club, team, or activity? What have you added to the group? How will having participated affect you in the future?

 

 
Essay Question: Please write about your desire at attend a United States service academy. Perhaps you may wish to describe the event(s) that made you interested in attending a service academy. Furthermore, you may want to write about a family member or friend who was influential in your decision-making. Please be clear in describing why attending a U.S. service academy is right for you.

 

 
In addition, please upload a Signature Page with the following information:

With my signature, I swear that the material contained in this application is truthful and accurate and the written material is my own.

Signature:

Date:

 

 

Letters of Recommendation: 

Please provide us with the names of three people who are writing letters or recommendations for your candidacy.  Please notify these individuals of your OCT 5, 2018 deadline so they can submit the letters online before the deadline.

 
Name

 

Title 

 

Relation to You: 

 

Years Known: 

 

 
Name:

 

Title: 

 

Relation to You: 

 

Years Known: 

 

 
Name

 

Title 

 

Relation to You:

 

Years Known: