USNA Form 1110/7 United States Naval Academy Request for Information

FRONT

OMB 0703-0036
EXP XX-XXX

UNITED STATES NAVAL ACADEMY
REQUEST FOR INFORMATION
PLEASE PRINT IN CAPITAL LETTERS

LAST NAME

M.I.

FIRST NAME

GENDER:

CELL PHONE

DOB (MM-DD-YYYY)

□

Male

□

Female

E-MAIL ADDRESS

Social Media Addresses
FaceBook: __________________________________________________________

HIGH SCHOOL
GRADUATION YEAR

Instagram: __________________________________________________________
Twitter:

__________________________________________________________

HIGH SCHOOL NAME

HOME ADDRESS

STATE

CITY

ETHNICITY:

RACE :

□
□

Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native

ZIP CODE

□ Black or African American
□

Caucasian

□ Asian

Are you Hispanic or Latino?

□

YES

□

NO

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0703-0036, 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.
Please do not return your response to the above address.
Responses should be sent to: United States Naval Academy, Candidate Guidance Office, 52 King George St., Annapolis, MD 21402-1300

See back for Privacy Act Statement

USNA 1110/7 (11-21)

For Internal Use:
SOURCE CODE:

Thank you for your interest in the United States Naval
BACK
Academy!

By completing this form you consent to the United States Naval Academy
Office of Admissions sending you periodic mail/emails/texts regarding Naval
Academy programs and events we are hosting in your area.
You can provide us your contact info in the following ways:
1. Go online to https://www.usna.edu/Admissions/Contact-Admissions-byEmail.php and complete the online Request for Information.
2. Hand the card to the Naval Academy representative at the event you are
attending.
3. Deliver the card to your Blue and Gold Officer.
4. Place the card in a sealed envelope and mail it to:
Department of the Navy
Dean of Admissions
United States Naval Academy
52 King George Street
Annapolis, MD 21402-9977
FOLLOW US ON SOCIAL MEDIA
Connect, follow and have a conversation with us.
Facebook: NavalAcademyAdmissions
Instagram: @usna_admissions
Twitter:
@usna_admissions
PRIVACY ACT STATEMENT
Authority: 10 U.S.C. § 503, Enlistments: recruiting campaigns; compilation of directory information; 10 U.S.C 2005; 10
U.S.C. 5013; 10 U.S.C. 8454; 10 U.S.C. 8456; 10 U.S.C. 347; 10 U.S.C. 8458; 10 U.S.C. 8462; 10 U.S.C. 8463; DoDI 1322.22;
E.O. 9397 (SSN), as amended; and N01531-1.
Purpose: To establish an audit trail of files which contain information on individuals as they progress from the
application stage, through the admissions process, to disenrollment or graduation from the Naval Academy.
Routine Uses: Used by the Admissions Office to collect information about potential candidates in order to provide them
with information regarding USNA programs and events.
Disclosure: Voluntary; however, failure to provide the required information may result in the inability to provide you
with information about USNA programs and events.