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U.S. SERVICE ACADEMY NOMINEE APPLICATION FORM
SENATOR MAX BAUCUS Order of Service Academy Choice: #1________#2_______#3______#4________ FULL NAME (First)__________(Middle) ________(Last)_____________________ LEGAL ADDRESS IN MONTANA__________________________________________ TELEPHONE_____________COUNTY_______________ TEMPORARY ADDRESS (If applicable)_____________________________________ TEMPORARY PHONE NUMBER___________________________________________
SOCIAL SECURITY NUMBER_____________________ DATE OF BIRTH________PLACE__________HEIGHT______WEIGHT______ VISUAL ACUITY (Uncorrected)_____________
FATHER'S NAME________________________OCCUPATION _________________ MOTHER'S NAME________________________OCCUPATION_________________
HIGH SCHOOL___________________________COUNSELOR____________________ SCHOOL PHONE_________________________YEAR OF GRADUATION_________ If you have attended college, where_____________How long__________
EXTRACURRICULAR ACTIVITIES: (Indicate grades where applicable) HIGH SCHOOL ONLY
____ Boys' State/Boys' Nation ____Eagle Scout ____Girls' State/Girls' Nation ____ Boy Scout ____President of Student Government ____Girl Scout ____ Other Student Government Offices ____Officer, School Club ____ President of Class ____Key Club ____ Other Class Office ____Language or Science Club ____ Student Council Member ____Officer, Non-School Club ____National Honor Society ____ Church Club ____ School Band/Chorus ____Jr. ROTC Officer ____Editor, School Publication ____ Jr. ROTC ____ Community Award (explain) ____ Other (explain)
IF YOU ARE EMPLOYED, HOW MANY HOURS PER WEEK:____AFTER SCHOOL_____ SUMMER____EXPLANATIONS:_________________________________________
ATHLETIC PARTICIPATION: (High School Only)
SPORT GRADE VARSITY POSITION LETTERS CAPTAIN AWARDS/HONORS
____I have taken the following tests on the dates indicated:
____I have not taken the required tests,
I am also seeking a nomination through________________________________ ________________________________________________________________
I have previously sought a nomination through___________________. When__________Results ____________
An optional essay may be written and attached. In approximately 300 words or less, please explain why you want to attend one of the U.S. Service Academies. See Information Sheet, Part III. Recommendation Letters: No more than 3 letters of recommendation from someone that knows you well PLEASE READ BEFORE SIGNING: I have read the Information Sheet explaining nomination procedures and am familiar with your requirements. I CERTIFY THAT I AM A LEGAL RESIDENT OF THE STATE OF MONTANA. If I have not submitted all necessary data by the 1st of December deadline, I understand that I may not be given final consideration for nomination.
DATE______________SIGNATURE_______________________________________
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