Please type or print:



Please type or print:

Congresswoman Kathy Castor

Application for Nomination to a U.S. Service Academy

It is my desire to attend the U.S. #1 ________________________________#2______________________________

Full Name: ___________________________________________________________________________________

Legal Address in Florida_________________________________________________________________________

Telephone _____________________________ County___________________________ Cong. Dist.____________

Temporary Address_____________________________________________________________________________

Temporary Address Timeframe_________________________________Temporary Phone____________________

Social Security #___________________Date of Birth____________________Place of Birth___________________

Height___________________________Weight_______________Uncorrected Visual Acuity__________________

Father’s Name ___________________________________Occupation____________________________________

Mother’s Name___________________________________Occupation_____________________________________

High School_________________________________________ Year of Graduation__________________________

High School Counselor_________________________________Phone____________________________________

Class Rank / Size_____________________Unweighted & Weighted GPA / Scale___________________________

Check one and complete:

___I have taken the following tests and scored accordingly on the dates indicated:

PSAT V:______ SAT V:______ W:______ ACT E:______ R:______

M:______ M:______ M:______ SCI:______

Date: _________________ __________________ ___________________

___I have not taken the required tests, but plan to take the SAT on____________________________________

PLEASE NOTE: SAT/ACT score reports should be received by the second week of November. The last available test for the SAT, to meet the

suggested deadline will be administered on October 6 and October 27 for the ACT. (The ACT code for Congresswoman Castor is 7331; SAT code is 5283)

If you have attended college: Where ___________________________________________________ #of years_________

Extra-Curricular Activities (attach additional sheet if necessary)

| Activity |Years Member | Position(s) Held | Awards Honors |

| | | | |

| | | | |

| | | | |

| | | | |

Athletic Participation (HIGH SCHOOL ONLY)

| Sport | Grade |Varsity | Position | Letters |Captain | Awards / Honors |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

Congresswoman Kathy Castor

Application for Nomination to a U.S. Service Academy

Applicant Name: ________________________________________________________________________

Page 2

If you are employed, how many hours per week ____________ After School__________________ Summer______

Explanation: __________________________________________________________________________________

_____________________________________________________________________________________________

I am also seeking a nomination through ____________________________________________________________

I have previously sought a nomination through ______________________________________________________

When __________________________________Results_______________________________________________

OPTIONAL essay may be written. In approximately 300 words or less, please state why you want to attend one of the U.S. Service Academies and what you want to pursue with your education.

PLEASE READ BEFORE SIGNING:

I have read the information sheet explaining the nomination procedure and I am familiar with the requirements. I CERTIFY THAT I AM A LEGAL RESIDENT OF THE STATE OF FLORIDA, 11TH CONGRESSIONAL DISTRICT. If I have not submitted all necessary information by the November deadline, I understand that I may not be given final consideration for a nomination by Congresswoman Kathy Castor.

I, the undersigned, declare that the information I have presented on this application form is true, correct, and complete to the best of my knowledge.

______________________________________________________________________

Signature of Applicant date

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