Congressman Mike Ross, 4th District of Arkansas :: Application for Nomination to United States Service Academies

Congress of the United States

Application for Nomination to
United States Service Academies

Personal

First Name	Middle Initial	Last Name

Suffix (Jr., III, etc.)	Race	Ethnicity

Address		(Area Code) - Phone Number

Address (Continued, if needed)

City	State	Zip Code

Email Address ( eg. me@myisp.com )

Date of Birth (mm/dd/yyyy)			Gender	Social Security Number (no dashes)
	/	/	Male
Month	/ Day	/ Year	Female

Education

High School (or Home School)	HS Grad Year		Class Rank		Class Size
				out of

Address		(Area Code) - Phone Number

Address (Continued, if needed

City	State	Zip Code

SAT:
VERBAL	MATH

ACT:
ENGLISH	MATH	READING	SCIENCE/ REASONING

GPA:

(Cumulative)

Activities

Organization (Gr. 9-12)	Check All that Apply	Sports Participation (Gr. 9-12)	# Years in Sport (Gr. 9-12)	# Varsity Letters (Gr. 9-12)	Team Captain (# Years)	# Years Special Recognition	(Explain in Remarks)
Student Body Officer
Class President
Officer School Club
Member School Club
Editor School Publication
School Band/Chorus		Have you ever been convicted of a felony/misdemeanor?				Yes	No
Boys/Girls State		(If yes, explain in remarks.)
National Honor Society		I authorize release of my candidate information to my parents.				Yes	No
Officer Non-School Club		I authorize official representatives of U.S. Representative Mike Ross to receive my official transcripts.				Yes	No
Scouting		I authorize the Educational Testing Service and ACT to release any record of non-standard testing to U.S. Representative Mike Ross.				Yes	No
Civil Air Patrol/ROTC						Yes	No
Eagle Scout/Gold Award
Senior Patrol Leader
Other(specify)

Remarks:

Acknowledgement

I understand that the deadline for submission of this application is November 30. Further, I recognize that three completed Evaluation Forms, a copy of Official School Transcripts (High School, college if applicable), and ACT and/or SAT Test Scores must be received by the November 30 deadline. If I have not submitted all the requested information before these deadlines, I realize that my application will not be full consideration.

I attest that by checking the box below I am providing my signature electronically and that the information provided in this Application for Nomination to the United States Service Academies is truthful and correct to the best of my knowledge.

Please submit required materials no later than November 15, to:

Via postal mail:

U.S. Representative Mike Ross
Attn: Service Academy Nominations
314 Cannon HOB
Washington, DC 20515

-or-

Via facsimile:

(202) 225-1314

(Please check the box to the left to verify your signature.)