United States Service Academy

United States Service Academy Application for Nomination

Representative Fred Upton 157 S. Kalamazoo Mall, Suite 180 Kalamazoo, Michigan 49007 (269) 385-0039 www.upton.house.gov APPLICATION FOR NOMINATION

1. NAME: Click here to enter text. (last, first, middle)

2. DATE OF BIRTH: Click here to enter text. (year, month, day)

3. SOCIAL SECURITY NUMBER: Click here to enter text.

4. HOME ADDRESS: Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

5. COUNTY IN WHICH YOU RESIDE: Click here to enter text. YOUR HIGH SCHOOL: Click here to enter text.

6. HOME TELEPHONE NUMBER: Click here to enter text. CELLULAR TELEPHONE NUMBER: Click here to enter text. EMAIL: Click here to enter text. CONTACT NUMBER AT COLLEGE/PREP SCHOOL: Click here to enter text.

7. NAME OF PARENT(S) OR GUARDIAN(S): Click here to enter text.

8. ADDRESS, IF DIFFERENT THAN YOURS: Click here to enter text. Click here to enter text. Click here to enter text.

9. ARE YOU A CITIZEN OF THE UNITED STATES OF AMERICA? Choose an item.

10. HAVE YOU, OR ARE YOU EXPECTING TO APPLY FOR A NOMINATION THROUGH ANOTHER SOURCE? Choose an item.

IF YES, PLEASE STATE OTHER SOURCE: Click here to enter text.

11. PLEASE LIST, IN ORDER, YOUR ACADEMY PREFERENCE: Choose an item. ARMY Choose an item. NAVY Choose an item. AIR FORCE Choose an item. MERCHANT MARINE

NOTE: YOUR “PREFERENCE” MAY BE CHANGED AS LATE AS THE DAY OF YOUR PERSONAL INTERVIEW. Item 12: Proof of Residency Please provide proof of residency for the 6th Congressional District in Michigan, by attaching a copy of one of the following documents: - Valid Michigan drivers license - Property tax documents - Federal or Michigan Income tax documents

NOTE: FAILURE TO PROVIDE PROOF OF RESIDENCY WILL DISQUALIFY YOU FROM NOMINATION. Item 13: School Related Extracurricular Activities: Please list all school related extra-curricular activities in which you have participated.

Click here to enter text. Item 14: Outside Activities: Please list all activities in which you participated outside of school, such as civic work, church involvement, or any other activities not associated with school.

Click here to enter text. Item 15: Work Experience

Click here to enter text. Item 16: One Page Essay: Please write a ONE page essay in which you state your reasons for wanting to attend a United States Service Academy.