U.S. Congressman MIKE POMPEO, Representing the 4th District of Kansas

Service Academy Nominations

Thank you for your interest in the U.S. Service Academies. As your 4th District Representative in the U.S. House of Representatives, each year I have the privilege of nominating a limited number of people to four of the five service academies. The honor of attending a service academy comes with an obligation and commitment to serve in the military for a minimum of five years upon graduation.

For more information please contact Toni Porter at my Home Office in Wichita at (316) 262-8992.

Best wishes to you as you pursue your goal of attending one of the U.S. Service Academies and serving our country.

To request a Service Academy Nomination form my office, please complete the form below.

Name:
First Name Middle Last Name

Permanent Address:
City: State: Zip:

Mailing Address:
(if different) City: State: Zip:

Email:
Phone:
SSN:
Date of Birth:
County:
Township:

US Citizen:
(Note: In order to enter the academy, an applicant who received an appointment must be a United States citizen at the time of entrance to the academy)
Choice of Academy: Please indicate order of preference (1, 2, etc.) and only those academies from which you would accept a nomination
Air Force Merchant Marine Military Navy
Current Applications:
ROTC Applications: Have you applied for a ROTC scholarship?

Father's Name:
Work Phone:

Mother's Name:
Work Phone:

Voting Registration: Are you or your parents registered to vote in Kansas' 4th Congressional District?


(Note: Applicant must be a bona fide resident of the 4th District to receive a nomination from Rep. Pompeo)

High School:
Guidance Counselor:
Guidance Office Phone:

SAT Scores:
Subject Test #1 Test #2 Test #3
Math
Verbal
Writing

ACT Scores:
Subject Test #1 Test #2 Test #3
English
Math
Reading
Science

Athletic Activities:
Sport JV V Awards/Honors Grade
9 10 11 12

Extracurriculars: Please list all school related groups or clubs as well as leadership positions you held and awards you received.
Activity Position Held Awards/Honors Grade
9 10 11 12

Community/Volunteer: Please list any and all participation in groups or clubs which are not school sponsored (e.g. Tutoring, Habitat for Humanity, Church groups)
Activity Position Held Awards/Honors Grade
9 10 11 12

Other Awards/Honors: Please list any you have received that have not previously been mentioned (e.g. DAR Awards, Governor's School, etc.)
Award/Honor Grade
9 10 11 12

Employment History: Please list any jobs you have held during the school year or summer, with a brief description of each

Medical Exam: Have you taken/been scheduled to take your medical exam administered by DODMERB?

Physical Exam: Have you taken/been scheduled to take your Physical Aptitude Exam?

If so, did you pass?

Medical Issues: Please indicate any medical problems (such as vision, asthma, hay fever, allergies, ADHD, etc.) and any corrective measures (glasses/contacts) or medications you are taking to correct these problems. Also include any and all surgeries you have had in the last ten years.

Criminal Information: Have you ever been convicted of a felony/misdemeanor?
(DO NOT include any speeding tickets, parking tickets, or other traffic violations for which you did not receive any points.)
If yes, please explain below.