0702-0060_Accepted Candidate Procedures_2.28.2022

OMB No. 0702-0060
OMB Approval Expiration
March 31, 2022
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0060, is estimated to average 266 minutes (25 minutes for the Pre-Candidate Phase, 195
minutes for the Candidate Phase, and 46 minutes for the Accepted Candidate phase) 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 [email protected]. 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.
PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title
44, United States Code, Public Printing and Documents, Ch 31, Sec 3101; Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons.
PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a candidate in order to open a file for admissions to
the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to provide information could preclude appointment. In addition to those disclosures generally
permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5
U.S.C. 552a(b)(3) as follows: Academic transcripts may be provided to educational institutions for the purpose of admissions to further educational degree programs. The
DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.
INSTRUCTIONS: The instructions for completing all required portions should be followed closely to ensure accurate data collection, and to preclude over-collection of information.
Instructions for completing all the required forms can be found in the Instructions of Applicants Offer Admissions booklet located on the candidate portal page.

OMB No. 0702-0060 OMB
Approval Expiration

March 31, 2022

CERTIFICATE OF AUTHORIZATION
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0062, is estimated to average 3 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 [email protected]. 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.

PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec 4346; Ch 505, Sec 5031; Ch
603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec 3101; Executive Order 9397, Numbering System for Federal
Accounts Relating to Individual Persons. PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather
information on a candidate in order to open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to provide
information could preclude appointment. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these
records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts
may be provided to educational institutions for the purpose of admissions to further educational degree programs. The DoD Blanket Routine Uses set forth
at the beginning of the Army's compilation of systems of records notices also apply to this system.
INSTRUCTIONS:
The instructions for completing the Certificate of Authorization should be followed closely to ensure accurate data collection, and to preclude over-collection
of information.
Instructions for completing the Certificate of Authorization can be found in the Instructions for Applicants Offered Admissions booklet located on
the candidate portal page.

I hereby appoint the United States Military Academy Cadet Accounting Services Office and his/her
successor or designee, as custodian and trustee of the initial deposit made by me and the total
pay and allowances accruing to me by reason of my appointment to, and duty as, a Cadet at the
United States Military Academy. Said custodian shall have the power to deposit said pay and
allowances in an account maintained for my use and benefit in such depository as he/she may
deem to be in my best interest.
The custodian shall have full authority to invest said funds and to use and/or expend said funds, or
any part thereof, for any interest and dividends generated by the Cadet Personal Trust Fund may be
used to pay the administrative cost of maintaining the Fund, including the salaries or any persons
directly employed by the Fund, whose salaries are not paid with appropriated funds. This certificate
of authorization is voluntarily made and shall be and remain in full force and effect during the entire
period of my appointment to, and duty as, a Cadet at the United States Military Academy unless
sooner revoked.

PRINT NAME (LAST, FIRST, MIDDLE [JR, II, ECT]

DATE

USMA Form 6-154 April 2017

SOCIAL SECURITY NUMBER

SIGNATURE

OMB No. 0702-0060
OMB Approval Expiration
March 31, 2022

STATEMENT OF CONSENT
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0062, is estimated to average 5 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 [email protected]. 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.

PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec
4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec 3101;
Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons. PRINCIPAL PURPOSE:
Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a candidate in order to
open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to provide
information could preclude appointment. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the
Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant
to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts may be provided to educational institutions for the purpose of
admissions to further educational degree programs. The DoD Blanket Routine Uses set forth at the beginning of the Army's
compilation of systems of records notices also apply to this system.
INSTRUCTIONS:
The instructions for completing the Statement of Consent should be followed closely to ensure accurate data collection, and to
preclude over-collection of information.
Instructions for completing the Statement of Consent can be found in the Instructions of Applicants Offer Admissions booklet
located on the candidate portal page.

I/We certify that
is not yet 18 years of age and has no
other legal guardian than me/us. I/We have read the entire contents of USMA 5-50. USMA form
5-50 consists of the Oath of Allegiance, the Agreement to Serve, and an affirmation of marital
status, child support, spousal support, and custody obligations; thereby obligating my/our son/
daughter in accordance with those terms.
Candidate's Social Security Number:

-

-

Date:

PARENT/LEGAL GUARDIAN

USMA Form 5-519 April 2017

OTHER PARENT/LEGAL GUARDIAN

OMB No. 0702-0060
OMB Approval Expiration
March 31, 2022

USMA/USMAPS Immunizations Record
1. Return completed "United States Military Academy Immunization Form", MEDCOM Form
829 and a copy of your original immunization records to the appropriate clinic as listed below:
*USMA - Mologne Cadet Health Clinic
[email protected] -or- Fax (845) 938-5777

*USMAPS (Prep School) - Keller Army Community Hospital Allgood Clinic
[email protected] -or- Fax (845) 938-0162

2. Please read the frequently asked questions prior to filling out forms. If you have a question that
is not answered on Appendix A then please contact the appropriate clinic listed below:
*USMA - Mologne Cadet Health Clinic (845) 938-3003
*USMAPS (Prep School) - Keller Army Community Hospital Allgood Clinic (845) 938-4114
3. All listed immunizations or equivalent testing are required except where annotated as *optional*
4. Complete all required immunizations before sending packet for review.
5. DO NOT UPLOAD TO THE CANDIDATE PORTAL.
6. Please allow two weeks for processing. You will be contacted via email once your packet has
been reviewed.
7. Many questions are geared toward the polio immunization. You will need an updated polio
vaccination, within the last year. This is IN ADDITION to the childhood series that is routinely given in
the United States. Please see the attached memo (last page of the packet). It is helpful for you to
bring this memo with you when you go get your immunization, as some providers may question the
need for this required polio vaccine.
CONSENT FOR RELEASE OF ADDITIONAL INFORMATION
I, __________________(Print name clearly) give my written
consent for the nursing staff at Keller Army Community Hospital, West Point, NY (Mologne
Cadet Health Clinic) to discuss my immunization records with a parent/guardian. This is
optional, however, often facilitates completion of your immunization records if there are any
questions.
Parent/Guardian Name: ______________________________________________________
Parent/Guardian Contact Number: _____________________________________________
Candidate Signature: ______________________________ Date: ____________________

USMA FORM 40-1 (DEC 2021) Previous Editions Obsolete.

United States Military Academy Immunization Form
*Print Clearly. No Cursive*
Last Name:

First Name:

DOB:

Gender:

Phone Number:

SSN:

MI:
Age on R-Day:

Are you allergic to any foods, medications, or stinging insects? NO

YES

Allergy: _______________________________ Reaction: ___________________________
Allergy: _______________________________ Reaction: ___________________________
Do you have seasonal allergies? NO

YES

Has your physician prescribed an EpiPen for you? NO

YES

If yes, please carry your EpiPen with you on R-Day with a prescription label attached.
Have you ever received treatment for an anaphylactic reaction to foods, medications or stinging insects?
YES

NO

If yes, please submit documentation of treatment. You may submit this in conjunction with your
immunization record.

YOU ARE REQUIRED TO HAVE THE FOLLOWING VACCINES.
Please use this worksheet to be sure that you have the required vaccines, in addition to the
official record from your physician.
Hepatitis A—TWO DOSES (or proof of immunity)

Dose #1: __________________
Dose #2: __________________

Hepatitis B—THREE DOSES (or proof of immunity)

Dose #1: __________________
Dose #2: __________________
Dose #3: __________________

**OR a combination of Hepatitis A and Hepatitis B (TWINRIX)—THREE DOSES
Dose #1: __________________
Dose #2: __________________
Dose #3: __________________

Last Name:

First Name:

MI:

Measles, Mumps and Rubella (MMR)—TWO DOSES (or proof of immunity)
Dose #1: _________________
Dose #2: _________________
Tetanus-diphtheria-pertussis (TDAP)—ONE DOSE of TDAP, received at 10 years old or later, after the
completed childhood series of DTAP. It is highly recommended to get an updated TDAP booster
prior to arrival.
Date: ___________________
Varicella (Chicken Pox)—TWO DOSES (or proof of immunity)
Dose #1: _________________
Dose #2: _________________
Meningococcal—ONE DOSE of Menactra or Menveo after the age of 16 –and—within the last 5
years.
Date: ___________________
Polio—ADDITIONAL DOSE AFTER THE COMPLETION OF THE CHILDHOOD SERIES, dose needs to be
within the last 12 months. THIS IS MANDATORY PER ARMY REGULATION 40-562.
Date: ___________________
COVID VACCINE:
Pfizer

Moderna

--TWO DOSES.

Dose #1: ________________
Dose #2: ________________

Johnson and Johnson—ONE DOSE

Date: ___________________

THE FOLLOWING VACCINATIONS ARE OPTIONAL—NOT REQUIRED.
HPV (Human Papillomavirus)—OPTIONAL. TWO or THREE DOSES DEPENDING UPON AGE THAT THE
VACCINE WAS STARTED.
AGE STARTED: _______
Dose #1: ________________
Dose #2: ________________
If Required, Dose #3: ________________
Meningitis B—OPTIONAL—TWO DOSES of Bexero or THREE DOSES of Trumenba.
Bexero

Trumenba

Dose #1: ________________
Dose #2: ________________
Dose #3: ________________

Last Name:

First Name:

MI:

TUBERCULOSIS SCREENING:
MEDCOM 829 FORM (ATTACHED) – Complete this form if you are new to the military or if you have never had a
TST (PPD) or IGRA blood test completed, or if you do not have the results of a previous TST (PPD) within the last 12
months or IGRA blood test. You must be able to submit results. History of receiving the BCG vaccine DOES NOT exempt
you from testing (if indicated on the form).
The Department of Defense requires that you receive treatment for Latent TB infection (LTBI).
This will NOT affect your admission to the United States Military Academy.

TST = Tuberculin Skin Test; IGRA = Interferon-Gamma Release Assays
Date Placed

Date Read

Result

Signature of Staff Reading
Result

Negative
Skin Test

________ mm
Last TST

Positive

(skin test)

Negative
OR
T-Spot or
QuantiFERON TB Gold
blood test for
tuberculosis

Date Drawn

Date Resulted

Interpretation

Last IGRA
(blood Test)

**MEDCOM Form 829 looks very confusing at first glance. Quick instructions: Answer questions 1-4. If all answers are
"NO", then no further action is needed. (The staff here at Mologne Cadet Health Clinic is the reviewer, so you do not
need a medical provider to sign this). If you answer "YES" to questions 2 or 3, refer to the following page which has a list
of countries. If the country that you mentioned on question 2 or 3 is listed here, you WILL NEED either a PPD/TST placed
or IGRA bloodwork drawn.
If you answer YES to question 5, please make an appointment with your healthcare provider immediately.
If you answer YES to question 6, ensure that you send that documentation along with your completed 40-1 packet and
immunization record. The staff at Mologne Cadet Health Clinic will review it and contact you directly if something more
is needed from you.

INITIAL ENTRY TUBERCULOSIS (TB) RISK ASSESSMENT TOOL
For use of this from see, MEDCOM Reg 40-64, the proponent agency is MCPO-SA

INITIAL ENTRY Tuberculosis (TB) Risk Assessment Tool

REVIEWER INSTRUCTION

1.

Have you ever had face-to-face contact with someone who
was sick with tuberculosis (TB)?

Yes

No

2.

Were you born outside the United States?
If yes, list country:
________________________________

Yes

No

3.

Did you ever live with a family member that was born outside
the United States?
If yes, list country:
________________________________

Yes

No

4.

Have you ever had a positive TB test, prior diagnosis of TB,
or prior treatment for TB?

Yes

No

Then do not test
5.

Do you have any of the following symptoms of tuberculosis?
Cough > 2 weeks, fever > 2 weeks, drenching night sweats,
or unplanned weight loss?
YES
NO

6.

Yes

No

If
immediately to provider for
evaluation of TB disease.

STOP.
6

Do you have documentation of previous TB treatment with you
today?

Yes

No

STOP.

Reviewer comments

YES

Do NOT test.

Document exemption in
MEDPROS

Test for TB.

Question 2 or 3 above, testing
is only required if the country is
Listed on the reverse side.
Name-last-first-middle; DOB; SSN; date; hospital or medical facility)

Name:
DOB:
SSN:
Date:
MEDCOM FORM 829, FEB 2014

REVIEWER NAME

REVIEWER SIGNATURE

Mologne Cadet Health Clinic Staff Mologne Cadet Health Clinic Staff

Page 1 of 2
MC PE v1.00

The following countries, if documented on the TB Risk Assessment Tool, indicate need for patient to be
tested:

Afghanistan
Algeria
Angola
Anguilla
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Belarus
Belize
Benin
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
China
China, Hong Kong SAR
China, Macao SAR
Colombia
Comoros
Congo
Congo DR
Cook Islands
Croatia
Djibouti
Dominican Republic
Ecuador
MEDCOM FORM 829, FEB 2014

Egypt
Malaysia
El Salvador
Maldives
Equatorial Guinea Mali
Eritrea
Marshall Islands
Estonia
Mauritania
Ethiopia
Mauritius
Fiji
Micronesia Fed States
French Polynesia
Moldova
Gabon
Mongolia
Gambia
Montenegro
Georgia
Montserrat
Ghana
Morocco
Guam
Mozambique
Guatemala
Myanmar
Guinea
N. Mariana Islands
Guinea Bissau
Namibia
Guyana
Nauru
Haiti
Nepal
Honduras
New Caledonia
India
Nicaragua
Indonesia
Niger
Iran
Nigeria
Iraq
Pakistan
Japan
Palau
Kazakhstan
Panama
Kenya
Papua New Guinea
Kiribati
Paraguay
Korea DR
Peru
Korea Rep of
Philippines
Kuwait
Poland
Kyrgyzstan
Portugal
Lao PDR
Qatar
Latvia
Romania
Lesotho
Russian Federation
Liberia
Rwanda
Libya
St. Vincent & Grenadines
Lithuania
Samoa
Macedonia
Sao Tome & Principe
Madagascar
Saudi Arabia

Senegal
Serbia
Serbia & Montenegro
Seychelles
Sierra Leone
Singapore
Solomon Islands
Somalia
South Africa
Sri Lanka
Sudan
Suriname
Swaziland
Syrian Arab Republic
Tajikistan
Tanzania-UR
Thailand
Timor-Leste
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Wallis & Futuna Islands
West Bank & Gaza Strip
Yemen
Zambia
Zimbabwe

Malawi
Page 2 of 2

Memorandum for Record Regarding Polio
DEPARTMENT OF THE ARMY
U.S. ARMY MEDICAL DEPARTMENT ACTIVITY
900 WASHINGTON ROAD
WEST POINT, NEW YORK 10996-1197

15 DEC 2021

MCUD-PC-CHC

MEMORANDUM FOR RECORD
SUBJECT: Polio vaccination in new military recruits
1. Every Candidate is required to get a polio booster to fulfil the required immunizations
for attendance at the United States Military Academy at West Point. This is in addition to
the childhood series routinely given in the United States.
2. Army Regulation 40-562 states that all accessions, to include students at military
academies, are to have a single booster dose of IPV because all military members are
expected to be ready to deploy or travel to countries with poor sanitation, therefore
putting them at an increased risk for contracting polio.
3. Point of contact for this memorandum is the undersigned at 845-938-3003.

Alicia Hughes, RN
Registered Nurse
Mologne Cadet Health Clinic

VISION EXAM

OMB No. 0702-0060
OMB Approval Expiration
March March 31, 2022

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0702-0062, is estimated to average 5 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 0MB control number.
PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch
403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch
31, Sec 3101; Executive Order 9397, Numbering System for Federal AccQunts Relating to Individual Persons.
PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather
information on a candidate In order to open a file for admissions to the United States Military. DISCLOSURE IS
VOLUNTARY. However, failure to provide information could preclude appointment In addition to those disclosures
generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may
specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic
transcripts may be provided to educational Institutions for the purpose of admissions to further educational
degree programs. The DoD Blanket Routine Uses set forth at the beginning of the Anny's compilation of systems of
records notices also apply to this system.

INSTRUCTIONS:
The instructions for completing the Vision Survey should be followed closely to ensure accurate data collection,
and to preclude over-collection of information.
Instructions for completing the Vision Survey can be found below.
PART I. You must complete all items in this section, whether or not you wear eyeglasses or contact lenses.
PART II. Only needed if you require vision correction full time. Recommend your Optometrist or Eye Physician
complete all items in this section so the West Point Eye Clinic can order two pairs of military glasses and one
EyePro insert for you prior to your arrival.

SPECIAL INSTRUCTIONS TO EYE DOCTOR
Spectacle Prescription: Even if your patient wears contact lenses full or part time, please complete the eyeglass
prescription in MINUS cylinder form which provides the best full-time wear distance visual acuity.
Frame size: The frame to be provided at West Point will be a medium weight, black plastic frame. It is S-10 shape
(10mm difference between vertical and horizontal lens dimensions.) If patient presently wears a frame of a
different style, write in the actual or estimated plastic frame size. Be sure to Include PD (Required). Standard base
curves will be ordered unless otherwise specified.
THIS FORM SHOULD REACH USMA NOT LATER THAN THE THIRD FRIDAY IN MAY. LATE APPOINTEES: PLEASE MAIL
AS SOON AS POSSIBLE.

USMA Form 5-490 APR 2019

OMB No. 0702-0060
OMB Approval Expiration
MarchMarch 31, 2022

PART I
1.

Name of Candidate (Last, First): _________________________________

2.

Sex:

3.

Are glasses or contact lenses required for clear or comfortable vision?

M

F
YES

NO

(If YES, you are urged to have PART II completed by your Optometrist, or complete information using most
recent spectacle prescription.)

PART II
1.
2.

SSN: _________________________________

Spectacle Prescription (In Minus Cylinder Form)
SPHERE
CYL
AXIS
OD
OS
Recommended Frame Size:

XS (46)

S (48)

PRISM

M (50)

ADD

DIST VA
20/
20/
L (52)

XL (54)

PD: ______
*PD is required. If PD measurement is blank, please go to local Optometrist or Optical Center to receive this
information.

Remarks: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

USMA Form 5-490 APR 2019

OMB No. 0702-0060
OMB Approval Expiration
March 31, 2022

POLICE RECORD CHECK
AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0702-0062, is estimated to average 5 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 [email protected]. 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.
PRIVACY ACT STATEMENT AUTHORITY: Title 5 United Sates Code, Government Organization and Employees, Ch 403, Sec 4346; Ch 505, Sec 5031; Ch 603, Sec 6958; Title 44, United States Code, Public Printing and Documents, Ch 31, Sec 3101; Executive Order 9397, Numbering System for Federal
Accounts Relating to Individual Persons. PRINCIPAL PURPOSE: Collection of data on Academy candidates for opening a file. ROUTINE USE: To gather information on a candidate in order to open a file for admissions to the United States Military. DISCLOSURE IS VOLUNTARY. However, failure to
provide information could preclude appointment. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, these records contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: Academic transcripts
may be provided to educational institutions for the purpose of admissions to further educational degree programs. The DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems of records notices also apply to this system.
The instructions for completing the Police Record Check should be followed closely to ensure accurate data collection, and to preclude over-collection of information.
Instructions for completing the Police Record Check can be found in the Instructions of Applicants Offer Admissions booklet located on the candidate portal page.

SECTION I-To be completed by applicant.
1. NAME OF APPLICANT (Last, First, Middle)

4. DATE OF BIRTH

2. SEX
Male
Female

3. PLACE OF BIRTH
a. City
b. County

5. RACE

6. SSN

a. Amer. Indian/Alaskan Native
b. Asian
c. Black or African American

7. ADDRESS
a. NUMBER & STREET/APT. NO.

c. State

b. CITY

d. Native Hawaiian or other Pacific Islander
e. White

8. DATES AT THIS ADDRESS
c. STATE a. FROM
b. TO

The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with federal law and regulations. Making a knowing
and willing false statement on this USMA Form 5-521 may be punishable by fine or imprisonment or both. All information provided by you, which possibly
may reflect adversely on your past conduct and performance, may have an adverse impact on you in your military career in situations such as consideration
for special assignments, security clearances, court martial and administrative proceedings, etc.

9. I HEREBY CONSENT TO RELEASE FROM YOUR FILES THE INFORMATION REQUESTED BELOW
SIGNATURE
DATE

SECTION II: (TO BE COMPLETED BY POLICE OR JUVENILE AGENCY)
The person described above, who claims to have resided at the address shown above, has applied to the United States Military
Academy at West Point. Please furnish from your files the information relative to Section II below. A return envelope is
provided for your convenience.
10. HAS THE APPLICANT A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?
YES If Yes, what was the offense or charge, date, disposition and sentence? Explain below.
NO

11. IS THE APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND?
If yes, give details.

MAIL TO:
DIRECTOR OF ADMISSIONS
UNITED STATES MILITARY ACADEMY
OFFICIAL MAIL & DISTRIBUTION CENTER
646 SWIFT ROAD
WEST POINT, NY 10996-1905

USMA FORM 5-521 April 2017

YES

NO

THIS IS TO CERTIFY THAT THE ABOVE DATA AS
CORRECTED ARE TRUE AND CORRECT ACCORDING TO
THE RECORD ON FILE IN THIS OFFICE. THIS INFORMATION
IS CONFIDENTIAL AND CANNOT BE USED IN ANY OTHER
MANNER EXCEPT FOR OFFICIAL PURPOSES.
12. DATE

13. TITLE

14. VERIFIED BY (Signature)