Academy or academies you would like to attend (in order of preference):

1.

2.

3.

4.

Name:

Gender:

Birthdate:

Permanent Address:

Social Security:

Temporary Address:

Temp. Phone:

High School Attended (Name & Address):

College: (If Applicable)

Father's Name:

Occupation:

Mother's Name

Occupation:

Please indicate grade (s)(High School only) you were in where applicable: (Attach extra sheet if needed.)

Extra - Curricular Activities:

Athletic Participation:

Honors & Awards:

Work Experience (Job title, hours per week, dates):

Other Congressional Office (s) Applied To:

Please Read Before Signing: I have read the attached Fact Sheet explaining the nominating procedure and am familiar with the requirements. I certify that I am a legal resident of the First Congressional District of the State of Hawaii. I understand that if all the necessary data have not been submitted by the November 30 deadline, I will not be eligible for a nomination.

Signature:

Date:

Please mail completed form to: Congressman Neil Abercrombie, P.O. Box 50143, Honolulu, HI 96850