Millitary Academy Nomination Form

Indicates required field

NOTE: Submission of an application does not guarantee an interview or nomination. Qualified applicants will be contacted regarding next steps in the selection process.

Your Information

Prefix:

First Name:

MI:

Last Name:

Suffix:

Date of Birth:

Email Address:

Phone Numbers

Primary Phone Number

Secondary Phone Number

Phone Type:

What are these options?

Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option 'Voice' is a standard audible telephone.

Permanent Address

Address

Address 2

City/Town

State

ZIP Code

Is your mailing address the same as your permanent address?

Yes

Mailing Street Address

Address 2

City

State

ZIP Code

Are you a citizen of the United States?

Yes

NOTE: Applicants must be U.S. citizens at the time of entrance to a service academy.

Parent / Guardian Information

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

Parent/Guardian Email Address:

Parent/Guardian Phone Number:

Do you reside in New York's 11th Congressional District?

Yes

NOTE: For USMA, USNA, and USAFA, applicants must be bona fide residents of New York's 11th Congressional District to receive a nomination from Rep. Malliotakis. For USMMA, applicants must be bona fide residents of New York State.

Education Information

High School:

Graduation Year:

Guidance Counselor Name:

Guidance Counselor Phone Number:

Academy Information

Please list only academies from which you would accept a nomination.

First Choice Academy:

Second Choice Academy:

Third Choice Academy:

Fourth Choice Academy:

Athletic Activities

Athletic Activities
	Sport: JV/Varsity: Captain? Yes No Grade(s) Participated: Awards/Honors:	Item weight

more items

Extracurricular Activities, Leadership & Honors

Extracurricular Activities

Extracurricular Activities
	Activity/Organization: Position Held: Grade(s): Awards/Honors:	Item weight

more items

Significant Experiences

Please describe any significant experiences, programs, travel, conferences, exchanges, seminars, or leadership opportunities that have helped shape your character and leadership abilities:

Employment History

Employment History
	Employer/Organization: Position: Dates: Description of Responsibilities:	Item weight

more items

Candidate Fitness Assessment (CFA)

NOTE: Please submit official CFA results only. Practice test results will not be accepted.

Push-Ups:

Pull-Ups:

Sit-Ups:

Shuttle Run:

Basketball Throw:

Mile Run Time (MM):

Enter your mile run time in minutes.

Official CFA Results:

Please submit official CFA results only. Practice test results will not be accepted.
One file only.
2 MB limit.
Allowed types: pdf jpg jpeg png.

Criminal Information

Have you been charged with a crime?

Yes

Have you been convicted of a felony or misdemeanor?

Yes

Are you currently the subject of a criminal investigation?

Yes

Have you been investigated by children/youth services for allegations of abuse?

Yes

If you answered YES to any of the above, please explain:

Supporting Documentation (Optional):

One file only.
2 MB limit.
Allowed types: pdf jpg jpeg png doc docx.

General Information

Are you applying to other nominating sources?

Senator Schumer

Senator Gillibrand

Vice President

Are you applying for an ROTC scholarship?

Yes

If yes, which schools?

Essay

Essay should be 750–1000 words.

What is something you want us to understand about you that has not been captured elsewhere in the application process and sheds significant light on who you are and how you move through the world?

Essay:

Word Count 1 word(s) — minimum 750, maximum 1000.

Personal Questionnaire

Please provide thoughtful but concise responses. Responses should not exceed 500 words each.

1. When did you decide you wanted to attend a service academy, and how was that interest developed?

2. What do you consider the most significant difference between a service academy and a traditional civilian institution of higher education?

3. Upon graduation, you will be commissioned as an officer in the United States Armed Forces. What career path do you hope to pursue, and why?

Uploads

SAT/ACT Scores:

One file only.
2 MB limit.
Allowed types: pdf jpg jpeg png.

High School Transcript:

One file only.
2 MB limit.
Allowed types: pdf jpg jpeg png.

Letter of Recommendation – Math or Science Teacher:

One file only.
2 MB limit.
Allowed types: pdf doc docx.

Letter of Recommendation – English Teacher:

One file only.
2 MB limit.
Allowed types: pdf doc docx.

Letter of Recommendation – Leadership/Character Reference:

One file only.
2 MB limit.
Allowed types: pdf doc docx.

Headshot Photograph:

One file only.
2 MB limit.
Allowed types: jpg jpeg png.

Additional Supporting Documents (Optional):

One file only.
2 MB limit.
Allowed types: pdf doc docx jpg jpeg png.

Certification & Signature

I certify that all information submitted is accurate, represents my own work, and that I understand the service commitment required of a service academy graduate.

Electronic Signature:

Date:

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