USNA Form 1110/5 ROTC Nomination to USNA

OMB 0703-0036
Exp: Renewal Pending

ROTC NOMINATION TO USNA
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8454, Midshipmen: number; 10 U.S.C. 8456, Midshipmen: nomination and selection
to fill vacancies; 10 U.S.C. 347, International engagement authorities for service academies; 10 U.S.C. 8458, Midshipmen: qualifications for admission;
10 U.S.C. 8459, Midshipmen: agreement for length of service; 10 U.S.C. 8461, Midshipmen: dismissal for best interests of the service; 10 U.S.C. 8462,
Midshipmen: discharge for unsatisfactory conduct or inaptitude; 10 U.S.C. 8463, Midshipmen: discharge for deficiency; DoDI 1322.22, Service
Academies; E.O. 9397 (SSN), as amended, and N01531-1.
PURPOSE: To obtain background information on ROTC candidates for granting nominations to the Naval Academy.
ROUTINE USES: Information will be used by the United States Naval Academy Admissions Office for awarding ROTC nominations.
DISCLOSURE: Voluntary; however, failure to provide the required information may prevent the candidate from being processed for a ROTC nomination
to the Naval Academy.
Please type or print all entries. Return nomination to: Office of Admissions Halsey Field House, 52 King George Street Annapolis, MD 21402.
We can not process a nomination unless the candidate has completed a Preliminary Application at www.usna.edu/admissions.
SECTION I. CANDIDATE INFORMATION
2. MAILING ADDRESS:

1. NAME (Last, First MI):

3. CANDIDATE NUMBER:

4. DATE OF BIRTH (Month, Day, Year):

6. HIGH SCHOOL GRADUATION YEAR:

5. GENDER:

7. CONGRESSIONAL STATE & DISTRICT:

SECTION II. SCHOOL AND NOMINATION INFORMATION
8. NAME OF SCHOOL/INSTITUTION:

9. MAILING ADDRESS:

10. EDUCATIONAL TESTING
SERVICE CODE (ETS):

11. PLEASE CHECK THE CORRECT BLOCK TO CERTIFY YOUR RECOMMENDATION FOR A NOMINATION. (You must also include a copy of
your unit order, so we can verify your eligibility to nominate):
NJROTC
MCJROCT

NAVAL/MARINE CORPS JUNIOR RESERVE OFFICER TRAINING CORPS - The candidate is currently enrolled in a
JROTC program at the institution listed. I recommend him/her for a nomination for appointment to the United States Naval
Academy under this category.

NROTC

NAVAL RESERVE OFFICER TRAINING CORPS - The candidate is currently enrolled in the NROTC program at the
college/university listed. I recommend him/her for a nomination for appointment to the United States Naval Academy under
the NROTC category.

NAVAL

HONOR SCHOOL - The candidate has been named an Honor Graduate or Prospective Honor Graduate of the institution
listed and this institution has been named Honor School with Distinction for the current academic year. I recommend him/
her for a nomination for appointment to the United States Naval Academy under this Honor School category.

MARINE
ARMY
AIR FORCE

PLEASE INCLUDE A SIGNED LETTER OF RECOMMENDATION ON YOUR UNIT OR SCHOOL STATIONARY WITH THE STUDENT'S NAME AND
CANDIDATE NUMBER ON THE TOP. PLEASE STAPLE RECOMMENDATION WITH THIS NOMINATION FORM.
12. PRINT OR TYPE NAME:

13. RANK:

14. POSITION:

15. TELEPHONE NUMBER (1st):

16. TELEPHONE NUMBER (2nd):

17. EMAIL ADDRESS (Mandatory):

18. SIGNATURE:

19. DATE:

Agency Disclosure Notice.
The public reporting burden for this collection of information, 0703-0036, is estimated to average 1 hour 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
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USNA 1110/5 (12-21)

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