USNA 1110/21 Nomination for Natural/Adopted Children of Active Duty/R

OMB 0703-0036
Exp: Renewal Pending

NOMINATION FOR NATURAL/ADOPTED CHILDREN OF ACTIVE DUTY/RESERVE/RETIRED PARENTS
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 5013, 10 U.S.C. 8454, 10 U.S.C. 8456, 10 U.S.C. 8458, 10 U.S.C. 8459, DoDI 1322.22, E.O. 9397 (SSN), as amended, and
N01531-1.
PURPOSE: To obtain background information on candidates for granting nominations to the Naval Academy.
ROUTINE USES: Information will be used by the United States Naval Academy Admissions Office and nominating office for awarding presidential
nominations.
DISCLOSURE: Voluntary; however, failure to provide the required information may prevent the candidate from being processed for a presidential
nomination to the Naval Academy.
***PLEASE NOTE: THIS NOMINATION IS FOR NATURAL/ADOPTED CHILDREN OF ACTIVE DUTY, RESERVE, OR RETIRED PARENTS ONLY***
This nomination request should be submitted after July 1st of the year prior to admission and before January 31st of the year of admission.
I request a Presidential nomination to the United States Naval Academy for the class that will enter in June of 20

, and I submit the following data.

SECTION I. CANDIDATE INFORMATION
1. NAME (Give full name as shown on birth certificate
or, if changed, attach a copy of court order):

2. DATE:

4. PERMANENT ADDRESS (Provide zip code plus 4):

5. MAILING ADDRESS (Provide zip code plus 4):

6. SEX:

7. DATE OF BIRTH:
Male

3. PHONE NUMBER:

8. CANDIDATE NUMBER (Required):

Female

9. NAME AND ADDRESS OF HIGH SCHOOL/COLLEGE:

11. CONGRESSIONAL STATE AND DISTRICT:

10. GRADUATION (Month/Year):

12. APPLYING TO SENATORS AND CONGRESSMAN (List names):

SECTION II. CANDIDATE MILITARY SERVICE INFORMATION
*** You must have active duty, reserve or retired military PARENTS to qualify for this nomination. Your military service may qualify you for a Secretary
of Navy nomination, see your Command Career Counselor for details.***
13. COMMAND:

14. RATE:

15. BRANCH OF SERVICE:

16. DUTY STATUS:

If member of the military, check here

SECTION III. APPLICANT'S PARENT MILITARY SERVICE INFORMATION
17. NAME AND RANK OF QUALIFYING PARENT(S) :

18. COMMAND:

19. BRANCH OF SERVICE: 20. DUTY STATUS:

I verify that I have included the proper supporting documentation of my parent’s military status with this application (check all that apply):
Active duty officers: statement of service signed by personnel officer specifying all periods of active duty.
Active duty enlisted: statement of service prepared by personnel officer specifying all periods of active duty and listing dates of enlistment and
dates of expiration of enlistment.
Reserves: proof of current service, including a copy of most current annual statement of reserve points (minimum points required 2880) and valid
identification card, or notice of eligibility (NOE) for retirement.
Retired with pay: copy of DD Form 214 (Member’s Copy 4)
Deceased or 100% disabled: Veterans Administration official determination of 100% disability or service connected death.
By signing block 21 below, I authorize disclosure of the information submitted in my admissions application to the nominating source and
their staff for use in the nomination selection process, and I declare under penalty of perjury that the foregoing is true and correct.
21. SIGNATURE:

22. DATE SIGNED:

Agency Disclosure Notice. The public reporting burden for this collection of information, 0703-0036, is estimated to average 15 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense,
Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not
display a currently valid OMB control number.
NOTE: Send completed forms to the Nominations and Appointments Office: Office of Admissions Halsey FIeld House, Attn: Nominations and
Appointments Office, 52 King George Street, Annapolis, MD 21402.
***We cannot process a nomination unless the candidate has completed a Preliminary Application at www.usna.edu/Admissions***

USNA 1110/21 (3-22)

Adobe LC ES4