Your Information Prefix: * - Select -Ms.Miss.Mrs.Mr.Mr. and Mrs.Rev.Dr.The HonorableRabbi First Name: * MI: Last Name: * Suffix: - None -2nd3rd4thIIIIIIVJr.Sr.M.D.PH.D.and Family Details Date of Birth: * Year Year199619971998199920002001200220032004 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Gender: * Female Male U.S. Citizen? * Yes No If not, list your country of citizenship: Parents/Guardians: Your Contact Information Street Address: * Street Address Continued: City: * State: * Zip Code: * +4 Extension: Email: * Telephone Phone Number: * Phone Type: Standard voice telephoneVideophone [VP]Text-telephone device [TTD] What are these options? Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option "Voice" is a standard audible telephone. Education Information Name of High School: * High School Street Address: * City: * State * Zip Code: * GPA: * Class Size: * Rank: * Graduation Date: * Year Year20182019202020212022 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Test Scores SAT Scores Math: Writing: Critical Reading: Composite: ACT Scores English: Math: Reading: Science: Composite: Academy Information Number your preference (1 to 4) of academies — with 1 being your highest preference. U.S. Air Force Academy: - None -1234 U.S. Merchant Marine Academy: - None -1234 U.S. Military Academy (West Point): - None -1234 U.S. Naval Academy: - None -1234 An appointment to the Service Academies is based on a desire by the candidate to devote a lifetime of military service and implies recognition by the appointee of an obligation to the government to devote him / herself to a military career. Are you interested in an appointment on that basis? Yes No Additional Information Name of hometown newspaper: Is it okay to use your name in a press release after receiving an appointment? Yes No CAPTCHAPlease help prevent spam; Thank You
