Toomey Academy Nomination Form – Fill Out and Use This PDF

United States Senator Pat Toomey

Service Academy Nomination Application

for the Class Entering in 2012

BIOGRAPHICAL INFORMATION

Full Name:

_____________________________________________________________________________

FirstMiddleLast

Name(s) of Parent(s)/Guardian(s):

______________________________________________________________________________

Are either of your parents a career military officer?

฀No

฀Yes

If yes, please give details: _____________________________________________________

Permanent Address:

_____________________________________________________________________________

Street

City

State

Zip

County

Temporary Address (If different from Permanent Address):

_____________________________________________________________________________

Street		City	State	Zip	County
Telephone Number:			Cell Phone Number:
____________________________			____________________________
E-Mail Address:			Social Security Number:
____________________________			____________________________
Gender:			Date of Birth:
฀	Female		____________________________
฀	Male		MM/DD/YYYY

To which Service Academy are you seeking a nomination? (Choose 1)

฀U.S. Air Force Academy

฀U.S. Merchant Marine Academy

฀U.S. Military Academy

฀U.S. Naval Academy

ACADEMIC INFORMATION

High School:

______________________________________________________________________________

High School County:	Year of Graduation:
____________________________	____________________________

High School Counselor’s Name and School Telephone Number:

______________________________________________________________________________

Are you currently attending college?

฀No

฀Yes

If yes, please provide name and address of college:

______________________________________________________________________________

______________________________________________________________________________

Are you currently in the military?

฀No

฀Yes

If yes, which branch?

______________________________________________________________________________

GPA:	Class Rank:
____________________________	____________________________

Please list any academic honors or awards received:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SAT Scores (Please list all test dates and scores):

Test Date: _____________Reading: __________ Math: __________ Writing: __________

Test Date: _____________Reading: __________ Math: __________ Writing: __________

Test Date: _____________Reading: __________ Math: __________ Writing: __________

Test Date: _____________Reading: __________ Math: __________ Writing: __________

ACT Scores (Please list all test dates and scores):

Test Date: _____________English: __________ Math: __________ Reading: __________

Science: _____________ Writing (if applicable): _____________

Test Date: _____________English: __________ Math: __________ Reading: __________

Science: _____________ Writing (if applicable): _____________

Test Date: _____________English: __________ Math: __________ Reading: __________

Science: _____________ Writing (if applicable): _____________

Test Date: _____________English: __________ Math: __________ Reading: __________

Science: _____________ Writing (if applicable): _____________

OR

I have not taken the required tests, but do plan to take the SAT/ACT on ____________________

SCHOOL-SPONSORED ATHLETIC AND EXTRACURRICULAR ACTIVITIES

OrganizationYears InvolvedLeadership Positions

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

OTHER ATHLETIC AND EXTRACURRICULAR ACTIVITIES
Organization	Years Involved	Leadership Positions

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

EMPLOYMENT INFORMATION
Employer	Position	Hours Per Week	Dates of Employment

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

ADDITIONAL INFORMATION

From whom will you seek letters of recommendation? What is his or her relationship to you? Letters of recommendation must come from teachers, counselors, coaches, or community contacts. No family member is permitted to write a letter of recommendation.

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

Have you ever attended an Academy Summer Seminar?

฀No

฀Yes

If yes, please specify which Academy Summer Seminar and year of attendance:

______________________________________________________________________________

Are you seeking a nomination through another Member of Congress?

฀No

฀Yes

If yes, please specify which Member of Congress:

______________________________________________________________________________

Do you wear glasses?		Do you wear contact lenses?
฀	No	฀	No
฀	Yes	฀	Yes

ESSAY

Please include an approximately 300-word typed essay indicating what motivates you to seek admittance to a Service Academy.

CERTIFICATION

Your signature below indicates that:

“I am a citizen of the United States, or I will have obtained citizenship before I enter the Academy. I am a legal resident of Pennsylvania. I certify that all of the information presented in my application is true and correct to the best of my knowledge. I understand that all of the necessary information and supporting materials must be postmarked by October 1, 2011 to be considered for a nomination by U.S. Senator Pat Toomey. I further certify that my application is motivated primarily by a desire to serve my country as a

professional officer. It is my intention, if I receive an appointment, to graduate from the Academy. I make this pledge in good conscience.”

Signature:

____________________________

Date:

____________________________