Military Academy Nominations Form

Applicant Contact Information

Prefix: *

First Name: *

Last Name: *

Suffix:

Preferred Name or Nickname: *

Date of Birth: *

Age: *

Gender: *

Street Address: *

Street Address: (Continued)

City: *

State: *

Zip Code: *

Email Address: *

Phone Number: *

U.S. Citizen? * Yes No

Country of Citizenship:

If you are currently in the military service, please provide the following information:

Branch of Service:

Rank:

Length of Service:

Academy Information

Please rank your preferred academies (first to fourth) – with first being your highest preference. If you have not applied to an academy, please choose N/A and do not rank. Only rank the academies to which you have applied.

First Pick:

Second Pick:

Third Pick:

Fourth Pick:

In addition to my application with Congressman Rouzer, I am applying for a nomination from:

Senator Ted Budd

Senator Thom Tillis

Presidential

Vice Presidential

ROTC

Parent/Guardian Information

Names of Parents/Guardians: *

Street Address: *

City: *

State: *

Zip Code: *

Education Information

High School Name: *

High School Address: *

City: *

State: *

Zip Code: *

High School Phone: *

Counselor Name: *

Graduation Date: *

Class Size: *

Class Rank: *

GPA Weighted: *

Grade Scale Used: *

Grade point average, scale, class rank and size must be included on your high school transcript. Home schooled students – please mark class rank/size as 1 of 1 if official ranking is unavailable.

ACT/SAT scores reported on your official certified transcript are acceptable. Otherwise, please have your official scores sent directly from the testing service.

SAT code: 5554 ACT code: 7585

College (if applicable)

GPA:

Hours Completed:

Major:

Extracurricular School and Community Activities

Awards and Honors

Community Involvement

Additional Information

Name of Hometown Newspaper:

Newspaper Street Address:

Is it ok to use your name in a press release after receiving an appointment? Yes No

Why are you seeking a nomination from Congressman Rouzer to a U.S. Military Service Academy? Please submit your statement in 250 words or less *

Please provide a photo, a student resume detailing your extra-curricular activities, an official high school transcript, and three (3) letters of recommendation supporting your nomination. One letter must be from your high school principal or school guidance counselor. Please submit the documents in a sealed envelope with the author’s signature written across the envelope flap.

CONGRESSMAN DAVID ROUZER
ATTN: LISA LITTLER
225 Green Street
Suite 202
Fayetteville, NC 28301

I understand I must contact the office to change any responses once submitted.

I acknowledge that the information I am submitting is complete and accurate.