Congressional District’S - Service Academy Application

PENNSYLVANIA 1ST CONGRESSIONAL

DISTRICT’S ACADEMY NOMINATION CHECKLIST

NAME: ______________________________________ TELEPHONE: ___________________________

PERMANENT ADDRESS: ______________________________________________________________

TEMPORARY ADDRESS: ______________________________________________________________

SOCIAL SECURITY NUMBER: ________________________ BIRTH DATE: ___________________

PLACE OF BIRTH: ____________________________________________________________________

HIGH SCHOOL: ______________________________________________________________________

GPA: ______________ RANK IN CLASS (IF KNOWN): ___________ OF ___________ STUDENTS

TEST SCORES: SAT VERBAL: _________________ MATH: __________________

ACT ENGLISH: _________________ MATH: __________________

EXTRACURRICULAR ACTIVITIES:

NUMBER IN ORDER OF PREFERENCE:

( ) US AIR FORCE ACADEMY

( ) US MERCHANT MARINE ACADEMY

( ) US MILITARY ACADEMY (WEST POINT) ( ) US NAVAL ACADEMY

MOTHER’S NAME: ________________________________________ PHONE:

FATHER’S NAME: ________________________________________ PHONE:

ADDRESS: __________________________________________________________________________

PLEASE RETURN THIS FORM TO:

Mr. GEORGE PEREZ

C/O CONGRESSMAN ROBERT A. BRADY

2630 MEMPHIS STREET

PHILADELPHIA, PA 19125