Service Academy Nominations Application

Thank you for your interest in the U.S. Service Academies. As your 1st 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 review my page of Frequently Asked Questions for those seeking a Military Academy Nomination. 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 Military Academy Nomination from 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

Current Applications:
ROTC Applications: Have you applied for a ROTC scholarship?

Father's Name:
Work Phone:

Mother's Name:
Work Phone:
Mother or Father's Email:

Voting Registration: Are you or your parents registered to vote in Mississippi's 1st Congressional District?

(Note: Applicant must be a bona fide resident of the 1st District to receive a nomination from Rep. Kelly)

High School:
School Principal's Name:
School Phone Number:
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.

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District Offices

Washington, D.C.

1721 Longworth H.O.B.
Washington, DC 20515
P:
(202) 225-4306
fax(202) 225-3549

Columbus, MS

318 North 7th Street, Suite D
Columbus, MS 39701
P: (662) 327-0748

    fax(662) 328-5982

Eupora, MS

855 South Dunn Street
Eupora, MS 39744
P:
(662) 258-7240
fax(662) 258-7240

Farmington, MS

4135 County Road 200
Corinth, MS 38844
P:
(662) 687-1525
fax(662) 841-8845

Hernando, MS

2565 Caffey Street, #200
P.O. Box 218
Hernando, MS 38632
P:
(662) 449-3090
fax(662) 449-4836

Tupelo, MS

431 West Main Street
Tupelo, MS 38804
P:
(662) 841-8808
fax(662) 841-8845