GIVE YOUR FIRST, SECOND AND THIRD CHOICES OF ACADEMIES:

#1_____________________ #2_____________________ #3_____________________

Date of Birth:_______________ Place:______________________

Social Security Number:________________________

LEGAL ADDRESS IN NINTH DISTRICT, ILLINOIS:________________________________________________

_______________________________________________________________________________________

TELEPHONE NUMBER:_________________________

TEMPORARY ADDRESS:_______________________________________________________

UNTIL WHAT DATE:_________________________ TELEPHONE NUMBER:______________

HEIGHT:_________ WEIGHT:_________ UNCORRECTED VISUAL ACUITY______________

FATHER'S NAME______________________OCCUPATION:___________________________

MOTHER'S NAME______________________OCCUPATION:___________________________

NAME OF HIGH SCHOOL:_____________________ YR.GRADUATING_________________

COUNSELOR'S NAME:________________________ TELEPHONE NUMBER:_____________

COLLEGE BOARD EXAMINATIONS INFORMATION:

I have taken the following tests on the dates indicated: SAT_____ ACT_____

I have not taken the required tests, but plan to take SAT on:______________

HAVE YOU ATTENDED COLLEGE, WHERE?______________________ HOW LONG?________

EXTRA-CURRICULAR ACTIVITIES - HIGH SCHOOL ONLY:

(Indicate grade/s for all that apply)

___BOYS' STATE/NATION ___EAGLE SCOUT  ___SCHOOL BAND/CHORUS

___GIRLS'STATE/NATION  ___BOY SCOUT   ___JR. ROTC OFFICER

___PRESIDENT-STUDENT GOV'T  ___GIRL SCOUT  ___JR. ROTC

___OTHER STUDENT GOV'T  ___OFFICE, SCHOOL CLUB   ___EDITOR, SCHOOL PUB.

___PRESIDENT OF CLASS   __KEY CLUB   Yearbook/Newspaper

___OTHER CLASS OFFICE  __LANGUAGE/SCIENCE CLUB  ___COMMUNITY AWARDS

___STUDENT COUNCIL MEMBER  __OFFICER,NON-SCHOOL (explain)

___NATIONAL HONOR SOCIETY  __CHURCH CLUB  ___OTHER (explain)

ATHLETIC PARTICIPATION-HIGH SCHOOL ONLY:

___SPORT ______GRADE ___VARSITY __POSITION __LETTERS __CAPTAIN __AWARDS/HONORS

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

EMPLOYMENT INFORMATION:

If you are employed, WHERE:________________________________________________

HOW MANY HOURS PER WEEK:_______________________ AFTER SCHOOL:_____________

SUMMER HOURS:_________________________

Explanation:_______________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

OTHER NOMINATION INFORMATION:

I am also seeking a nomination through:____________________________________

___________________________________________________________________________

I have previously sought a nomination through - name person, when, results:

___________________________________________________________________________

PLEASE READ BEFORE SIGNING

I have read the Information Sheet explaining the nominating procedure of Congresswoman Schakowsky and I am familiar with her requirements. I CERTIFY THAT I AM A LEGAL RESIDENT IN THE NINTH DISTRICT OF ILLINOIS. If I have not submitted all necessary data by the December 8 deadline, I

understand that I may not be given final consideration for a nomination.

(Optional essay may be written on back. In no more than 300 words, please state why you want to attend one of the United States Service Academies.)

DATE:_____________________ SIGNATURE:___________________________________