Service Academy

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Your Information

Prefix:

First Name:

MI:

Last Name:

Suffix:

Details

Date of Birth:

Month

Day

Year

Gender:

Female

Male

U.S. Citizen?

Yes

If not, list your country of citizenship:

Parents/Guardians:

Your Contact Information

Address

Address 2

City

State

ZIP

Email:

Telephone

Cell Phone Number:

Home Phone Number:

Parent or Guardian Phone Number:

Education Information

Name of High School:

Address

Address 2

City

State

ZIP

Graduation Year

Academy Information

Are you requesting a nomination to a service academy from source other than Congressman Williams?

Please include name and/or type of nominating source, i.e. Presidential, Foundation, etc.

ANY DESIRE TO CHANGE YOUR ORDER OF PREFERENCE REQUIRES A NEW APPLICATION

I certify that my answers are true and complete to the best of my knowledge. I understand that provisions of the Privacy Act of 1974 are waived to the extent of sharing this information with the service academies, their representatives, and members of the Candidate Selection Board. Additionally, I understand that if a nomination or an
appointment is offered to me by a service academy, any announcement to the news media will be made by Congressman Williams only.

Type your full name to agree to the above:

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