2011 Application For Service Academy Nomination

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201420162011 Service Academy Nomination Application – Class of 2019Congressman Hank JohnsonGeorgia Congressional District 4Deadline: Monday, centcolor photoContact InformationNAME:HOME STREET ADDRESS:CITY/STATE/ZIP:COUNTY:STUDENT E-MAIL:HOME PHONE:STUDENT CELL PHONE:DOB:SSN:PARENT OR GUARDIAN’S NAME:PARENT OR GUARDIAN’S DAYTIME PHONE:LOCAL NEWSPAPER:HIGH SCHOOL:SCHOOL PHONE:IF YOU ARE ATTENDING A COLLEGE OR ACADEMY PREP SCHOOL, PLEASE NAME THE SCHOOL:IF YOU ARE SELECTED FOR A SERVICE ACADEMY, WHICH ACADEMIC AREA DO YOU INTEND TO PURSUE?ACADEMY PREFERENCE – You are not required to rank all academies. Only indicate a preference for the schools to which you have an openadmissions file. INDICATING YOUR PREFERENCES WILL NOT IN ANY WAY AFFECT MY CONSIDERATION OF YOUR FIRST CHOICE.(PLEASE USE THESE CODES – USAFA, USMMA, USMA, USNA)1ST CHOICE2ND CHOICE3RD CHOICE4TH CHOICE

Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 2PLEASE PROVIDE BRIEF RESPONSES TO THE FOLLOWING QUESTIONS1. Have you ever been involved in an honor violation, placed on school probation or dismissed from school? If so, please explain and attach aschool statement detailing the resolution of the situation.2. What is the most significant contribution that you have made to your school, church or community?3. Have you, your friends or family members attended a service academy? If so, what is your impression of the experience? Answers should be typed and fit into space provided.ESSAY QUESTION (500 WORDS OR LESS)

Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 3Most Junior Officers faces deployment in support of the nation's military efforts, both in peace and wartime. What motivations influence yourgoal of being an Officer in the United States Armed Services during a period of increased danger and potential personal and familysacrifices.?Please print and attach your essay to this application. Make sure your name is on each page.

Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 4Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291ACTIVITIES QUESTIONNAIREPlease mark the appropriate years that you have participated in an extra-curricular or physical activity in the space provided next to it.EXTRA-CURRICULAR ACTIVITIESPre-991011AWARDS12Pre-9President of ClassJr. ROTCOther Class Office:Officer ROTC9101112In the space provided below, please listhonors, prizes or awards you have received.Eagle Scout/Gold AwardKey ClubPresident of Student Govt.Language ClubOther Student Govt. Office:Math ClubNational Honor SocietyWho’s Who or DistinguishedModel UNBoy/Girl ScoutPeer Counselor/TutorBoy’s/Girl’s StateScience ClubBoy’s/Girl’s NationStudent CouncilChess TeamVarsity Letter ClubCivil Air PatrolOther ClubsComputer ClubDebateJunior AchievementHigh School StudentOTHER AWARDS

Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 5Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291ACTIVITIES QUESTIONNAIRE (continued)PHYSICAL ACTIVITY (Organized school activities only. Indicate number of years of participation in selected categories.)C CaptainV Varsity JV Junior VarsityC CaptainWORK EXPERIENCE (or Community Service)V Varsity JV Junior VarsityArcheryTennisAfter leyballCheerleadingWeightliftingHours Worked per ion:EquestrianEmployer:FencingField HockeyHours Worked per Week:After School/WeekendFootballGolfYearYearYearINTRAMURAL PARTICIPATION (Indicate sport & numberof years of participation in each sport)Employer:GymnasticsPosition:Ice HockeyLacrosseHours Worked per Week:SoccerSwimming

Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 62014 Service Academy Nomination Application – Class of 2019APPLICANT CONTRACTThis form is to be completed by the applicant.As the applicant, I am responsible for the content and deadline of this application.I certify that the information I have provided in this application is true and complete. I will notify Congressman Johnson promptly if there is anychange in any aspect of this application.No final action will be taken on my application until all required information is received.DATE:SIGNATURE:PRINTED NAME:SOCIAL SECURITY NUMBER:

Name:Deadline: Monday, OctoberOctober 31,5:00pmpm27,201,2014,5:00Application Page 7Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291AFFIDAVIT OF DOMICILEThis form is to be completed by the parent or legal guardian of the individual seeking my nomination to a United States Service Academy. If youare not a minor, the form may be completed by you.This statement establishes that the applicant and his/her parent or guardian is domiciled in the State of Georgia, 4th Congressional District.Domicile is defined as a person’s fixed, permanent and principal home for legal purposes., being of lawful age (18) and a resident ofI,, Georgia,(city/county)do on oath and under penalties of perjury, depose and say:1. That I am the parent entitled to the custody of, or the legal guardian of, a minor, or am theapplicant who has reached the age of majority, who has applied to Congressman Henry Johnson for consideration as a nominee to a UnitedStates Service Academy; that the said individual is either my son/daughter and is my legal ward who lives with me; and thatour/my domicile is(address, including city or town, state and zip code)2. This is in evidence thereof, I depose and say that:I am registered as a voter in(city, county and state)And I file tax returns and pay state income taxes to the State ofSignatureDate

Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 8Application for Service Academy Nomination – Class of 2019Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291PRINCIPAL/GUIDANCE COUNSELOR OFFICIAL TRANSCRIPT FORMThis form must be completed by your High School Principal, High School Guidance Counselor or High School Registrar. In a sealedschool envelope, please attach to this form the transcript of the final junior grades, or final senior grades if graduated.NAME OF APPLICANT:LASTFIRSTMIDDLEADDRESS:NAME OF SCHOOL:ADDRESS OF SCHOOL:SCHOOL TELEPHONE:APPLICANT’S YEAR IN SCHOOL:GRADE POINT AVERAGE:4.O SCALE (must be provided)weighted scale (reference only)Students must request that the SAT & ACT Board scores be sent directly to my office from the College Testing Board,609-771-7600. My SAT Code is 1530. My ACT Code 7354. Scores listed on transcripts are not acceptable.DATE:SIGNATURE:TITLE:

Application for Service Academy Nomination – Class of2019 Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058CHECKLISTName:Deadline: Monday October 27, 2014, 5:00 pmApplication Page 9This checklist is for your personal reference only. You may keep these pages.Applicant ContractSigned Affidavid or DomicilePrincipal or Guidance Counselor Recommendation FormSigned letters of RecommendationMath teacherScience teacherPersonalExtra-curricular and athletic formsPrincipal/Guidance Counselor Official Transcript FormOfficial transcripts from high school or collegeOfficial SAT Scores from the College Testing Board (Code 1530) – (Scores printed on your transcripts are not acceptable.)Official ACT Scores from ACT, Inc. (Code 7354) – (Scores printed on your transcripts are not acceptable.)If your application is complete and you have an open file with the service academies of your choice, then you will be scheduled for an interview with my ServiceAcademy Nomination Review Board. You will be notified of the date and time of your interview in writing.US Military AcademyDirector of Admissions600 Thayer RoadWest Point, NY 10996-9902www.usma.eduUS Air Force AcademyHQ USAA/RRSUSAF Academy, CO 80840-9901www.usafa.af.milUS Military AcademyDean of Admissions117 Decatur RoadAnnapolis, MD 21402-9977www.nad.navy.milUS Air Force AcademyAdmissions OfficeSteamboat RoadKings Point, NJ 11024-1699www.usmma.edu

Application for Service Academy Nomination – Class 2019of 3 Congressman Hank Johnson5700 Hillandale Drive, Suite 120, Lithonia, GA 30058770-987-2291Name:Deadline: Monday, October 27, 2014, 5:00 pmApplication Page 10Helpful Hint!!!Consider the United States Coast Guard Academy! The Coast Guard Academy does not require a nomination.To obtain an application, contact:US Coast Guard AcademyDirector of Admissions15 Mohegan Ave.New London, Connecticut 06320-41951-800-883-8724Your entire completed application and test scores must be received in my Lithonia district office by5:00 pm, Monday, October 27, 2014, to receive consideration for a nomination. Partial applications willnot be considered. No exceptions!- Forms requiring signature--Applicant Contract – to be signed by applicant--Affidavit of Domicile – to be signed by parent--Principal/Guidance Counselor form – to be signed by Principal or Guidance Counselor and includedin a sealed envelope with your Official Transcript. If your school’s policy requires that the transcript be maileddirectly to our office, please provide the school with the address and deadline.---Principal or Guidance Counselor Recommendation Form- You will also need three signed letters of recommendation from:--- One math teacher--- One science teacher--- One adult non-family memberto the followingto the followingaddress:address:Please either mail or deliver the entire application packetService Academy Nomination Review BoardServiceReviewTheAcademyOffice of NominationCongressmanHankBoardJohnsonThe Office of Congressman Hank Johnson5700 Hillandale Drive, Suite 1205700 Hillandale Drive, Suite 120Lithonia, GA 30058

HANK JOHNSONUNITED STATES * GEORGIA2014 Principal or Guidance Counselor Recommendation FormName of Candidate:Name of School:Please comment on the following categories and list activities or demonstrative examples. Ifnecessary, please feel free to use additional pages. However, a recommendation letter will not beaccepted as a substitute for this completed form.1. Leadership Characteristics2. Personality Traits3. Ability to work under pressure4. Ability to get along with others5. MotivationSubmitted by:Title:Phone:Email:Signature:Date: Complete and submit this form in a sealed envelope with your signature across the sealby Monday, October 27, 2014 at 5pm.Service Academy Nomination Review BoardThe Office of Congressman Hank Johnson5700 Hillandale Drive, Suite 120Lithonia, GA 30058

US Military Academy US Air Force Academy. Director of Admissions HQ USAA/RRS . 600 Thayer Road USAF Academy, CO 80840-9901 . West Point, NY 10996-9902 . www.usafa.af.mil www.usma.edu. US Military Academy US Air Force Academy. Dean of Admissions Admissions Office . 117 Decatur Road Steamboa

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