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:

Yes No

(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:

Sen. Wicker Sen. Cindy Hyde-SmithVice President Service Related

ROTC Applications:

Have you applied for a ROTC scholarship? Yes No
If so, where?

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? Yes No
If so, which voting precinct?
(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?
Yes No
If so, when?

Physical Exam:

Have you taken/been scheduled to take your Physical Aptitude Exam?
Yes No
If so, did you pass? Yes No

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? Yes No
(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.

Are you currently charged with a felony or misdemeanor for which you have not been found guilty, and for which the court’s decision is currently still pending? Yes No

If yes, please explain below.