U.S. SERVICE ACADEMY NOMINEE APPLICATION FORM
SENATOR MAX BAUCUS
Silver Bow Center
125 West Granite
Butte, MT 59701
Order of Service Academy Choice: #1________#2_______#3______#4________
FULL NAME (First)__________(Middle) ________(Last)_____________________
LEGAL ADDRESS IN MONTANA__________________________________________
TELEPHONE_____________COUNTY_______________
TEMPORARY ADDRESS (If applicable)_____________________________________
TEMPORARY PHONE NUMBER___________________________________________
SOCIAL SECURITY NUMBER_____________________
DATE OF BIRTH________PLACE__________HEIGHT______WEIGHT______
VISUAL ACUITY (Uncorrected)_____________
FATHER'S NAME________________________OCCUPATION _________________
MOTHER'S NAME________________________OCCUPATION_________________
HIGH SCHOOL___________________________COUNSELOR____________________
SCHOOL PHONE_________________________YEAR OF GRADUATION_________
If you have attended college, where_____________How long__________
Email: ___________________________________________________________
EXTRACURRICULAR ACTIVITIES: (Indicate grades where applicable)
HIGH SCHOOL ONLY
____ Boys' State/Boys' Nation ____Eagle Scout
____Girls' State/Girls' Nation ____ Boy Scout
____President of Student Government ____Girl Scout
____ Other Student Government Offices ____Officer, School Club
____ President of Class ____Key Club
____ Other Class Office ____Language or Science Club
____ Student Council Member ____Officer, Non-School Club
____National Honor Society ____ Church Club
____ School Band/Chorus ____Jr. ROTC Officer
____Editor, School Publication ____ Jr. ROTC
____ Community Award (explain) ____ Other (explain)
IF YOU ARE EMPLOYED, HOW MANY HOURS PER WEEK:____AFTER SCHOOL_____
SUMMER____EXPLANATIONS:_________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
ATHLETIC PARTICIPATION: (High School Only)
SPORT GRADE VARSITY POSITION LETTERS CAPTAIN AWARDS/HONORS
CHECK ONE AND COMPLETE:
____I have taken the following tests on the dates indicated:
SAT__________ACT__________
____I have not taken the required tests,
but plan to take the SAT on ____ or ACT on_______
I am also seeking a nomination through________________________________
________________________________________________________________
I have previously sought a nomination through___________________.
When__________Results ____________
An optional essay may be written and attached. In approximately 300 words or less, please explain why you want to attend one of the U.S. Service Academies. See Information Sheet, Part III.
Recommendation Letters: No more than 3 letters of recommendation from someone that knows you well
PLEASE READ BEFORE SIGNING: I have read the Information Sheet explaining nomination procedures and am familiar with your requirements. I CERTIFY THAT I AM A LEGAL RESIDENT OF THE STATE OF MONTANA. If I have not submitted all necessary data by the 1st of December deadline, I understand that I may not be given final consideration for nomination.
DATE______________SIGNATURE_______________________________________
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