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pdfU.S. Merchant Marine Academy
OMB No. 2133-0010
300 Steamboat Road, Kings Point, New York 11024-1699
Expiration: 10/31/2018
CANDIDATE APPLICATION — PART 1
This collection of information is required to obtain benefits and will be used to determine the eligibility of respondents for admission to the
U.S. Merchant Marine Academy. Public reporting burden is estimated to average five hours 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. The U.S. Merchant Marine Academy does not consult or discuss any information with anyone not expressly designated by the candidate. Please note that
an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
The OMB control number for this collection is 2133-0010. Send comments regarding this burden estimate or any other aspect of this information collection to the
Maritime Administration, Office of Management and Administrative Services, 1200 New Jersey Avenue, SE, Room W28-302, Washington, DC 20590.
APPLICANT NAME: (Last, First, Middle, and Suffix (Jr., Sr., II, III, IV))
SOCIAL SECURITY NO.
Day
Year
SEX
RACE (Select one or more)
Male
American Indian or Alaskan Native
January
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
March
0
0
0
0
April
1
1
1
1
May
2
2
2
2
June
3
3
3
3
July
4
4
4
August
5
5
5
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5
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September
6
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October
7
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8
8
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8
8
8
November
8
8
8
December
9
9
9
9
9
9
9
9
9
9
9
TELEPHONE NUMBER
Asian
February
4
9
www.usmma.edu
STATE OF RESIDENCE
DATE OF BIRTH
Month
If you wish to
complete this
application On-Line,
go to the
Academyʼs web site:
Female
Black or African American
Native Hawaiian or Other Pacific Islander
White
ETHNICITY
Hispanic or Latino
Not Hispanic or Latino
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
0
1
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$
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9
HOME ADDRESS: (Street, City, County, State, and Zip Code)
Your E-Mail Address:
MAILING ADDRESS: ( If different than home address above) (Street, City, County, State, and Zip Code)
Father:
Work Telephone No. (Area Code)
Parent/Guardianʼs Name
Home Telephone No.(Area Code)
CITIZENSHIP
U.S. Citizen
Not a
U.S. Citizen
Citizen of: ________________
Mother:
PLACE OF BIRTH
Guardian:
________________
(City and State)
Parent/Guardianʼs Address (If different than applicantʼs permanent address)
ACADEMIC MAJOR
Please supply the following information:
Logistics and Intermodal Transportation
Yes
No
Marine Engineering
Q.1
Marine Engineering Systems
Q.2
Chemistry (with Lab)?
Marine Engineering and Shipyard Management
Q.3
Physics (with Lab)?
Marine Transportation
Q.4
Is your visual acuity 20/400 or better?
Q.5
If not 20/20, is it correctable to 20/20?
Undecided
Have you ever applied to
the USMMA in past years?
On entering USMMA in July, will you have completed:
Trigonometry or Pre-Calculus (at least 1 Semester)?
Q.6
Do you have a history of asthma?
Q.7
Do you have problems with color vision?
Yes
No
If “yes”, when? (Year)
NAME OF HIGH SCHOOL OR PREP SCHOOL YOU ATTENDED/ARE ATTENDING: (Name, Address, City, State, and Zip Code)
DID YOU ATTEND COLLEGE OR PREP SCHOOL AFTER HIGH SCHOOL GRADUATION? (If you did, list that schoolʼs name and state):
College
Prep
IF YOU ARE CURRENTLY IN THE MILITARY (Guard, Reserve or Active Duty), WHAT IS YOUR PAY GRADE: E - 1
KP 2-65 (JANUARY 2012)
12-14693 MARAD part 1 pg 1
Continued on Reverse
2
3
4
5
SAT SCORES
VERBAL
MATH
0
0
0
ACT SCORES
ENGLISH
MATH
0
0
1
0
0
This item is not used as part of the qualification/selection process. The information you provide in this section will be
forwarded to the appropriate activity director. The director may contact you to learn more of your interest and
abilities, and to more fully inform you of the Academyʼs program in the area.
0
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
HIGH SCHOOL
ACTIVITIES
Yes
4
Baseball
5
Basketball
4
4
4
4
4
5
5
5
5
5
6
6
6
6
6
6
Crew
7
7
7
Cross-Country
8
8
8
Football
9
9
9
Golf
7
8
7
7
8
8
9
RANK IN CLASS
CAND.
CUM. GPA
0
0
0
1
1
1
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PARTICIPATION
No
VARSITY LETTER
One
Year
INTEND TO PARTICIPATE
IN COLLEGE
More Than
One Year
Yes
No
Lacrosse
Rifle
Top 5 Percent
Sailing
Top 10 Percent
Soccer
Top 20 Percent
Softball
Top 30 Percent
Swimming/Diving
Top 40 Percent
Tennis
Top 50 Percent
Track & Field
Lower 50 Percent
Wrestling
Volleyball
Drill Team
Height _________
Weight _________
Boy/Girl Scouts/Explorers/Campfire
Band/Orchestra/Chorus
Cheerleading
YEAR OF H.S.
H.S. ETS CODE
GRADUATION
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
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3
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3
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6
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7
8
9
0
Newspaper/Yearbook
Other (specify)
0
0
1
1
Have you served as Captain of an organized athletic team?
Yes
No
2
2
Have you served in a High School Student Government position?
Yes
No
3
3
4
4
4
Have you actively participated in community organizations such as Religious, Scouts, 4-H, Sea Cadets,
Coast Guard Aux., Civil Air Patrol, etc.?
Yes
No
5
5
5
5
Have you received special recognition such as Eagle/Gold Award, Boyʼs/Girlʼs State, Billy Mitchell Award, etc.?
Yes
No
6
6
6
6
6
No
7
7
7
7
7
7
8
8
8
8
8
9
9
9
9
9
1
2
9
8
8
9
9
Have you worked at least 10 hours per week during the school year?
Yes
Have you ever been rejected for any branch of the Armed Forces, ROTC, or Service Academy?*
Yes
No
Have you ever been arrested, indicted, or convicted of any violation of Civil or Military Law?*
(includes moving violations (speeding, DUI) but excludes parking violations.)
Yes
No
*If you answered “yes”, explain on a separated sheet of paper and attach it to this part when submitting it to the Academy
APPLICATION DEADLINE IS MARCH 1
An Appointment will not be considered unless Parts 2 and 3 and the Biographical Essay are also completed and received by the above deadline.
APPLICANTʼS SIGNATURE
DATE
Privacy Act Statement
In accordance with 5 USC 552a(e)(3), the following information is provided to you when supplying personal information to the Maritime Administration.
1. Authority which authorized the solicitation of the information: 46 App. USC 1295b and 1295g.
2. Principal purpose(s) for which information is intended to be used: The information is used to evaluate each applicant for an appointment to the
U.S. Merchant Marine Academy.
3. The routine uses which may be made of the information: As background information on applicants for the selection process. To contact the applicant.
The social security number is a basic identifier.
4. Whether or not disclosure of such information is mandatory or voluntary (required by law or optional) and the effects on the individual, if any, of not
providing all or any part of the requested information: Disclosure of the information is voluntary, but the applicant will not be considered further if all
information is not provided.
KP 2-65 (JANUARY 2012)
12-14693 MARAD part 1 pg 2
Continued on Reverse
OMB No. 2133-0010
U.S. Merchant Marine Academy
300 Steamboat Road, Kings Point, New York 11024-1699
CANDIDATE APPLICATION — PART 2
STATE OF RESIDENCE
APPLICANT NAME: (Last, First, Middle, and Suffix (Jr., Sr., II, III, IV))
SOCIAL SECURITY NO.
NOMINATION SOURCE(S): Indicate Name of U.S. Senator and/or Representative you:
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Applied to ________________________________________________________________________________________
Were Nominated by ________________________________________________________________________________
Who was your Initial Source of Information about the U.S. Merchant Marine Academy?
Academy Admissions Office
Academy Faculty
HS Coach
Relative
Academy Field Rep. or Alumni/ae
Congressional Office
HS Counselor
Other (Identify):
Academy Athletic Coach
Friend
HS Faculty
____________________
If you have applied to any other U.S. Service Academies and/or any of the State Maritime Schools, please check the appropriate box(es) below:
USAFA
USMA
California Maritime
Maine Maritime
New York (SUNY) Maritime
USCGA
USNA
Great Lakes Maritime
Massachusetts Maritime
Texas (A&M) Maritime
IDENTIFY ONLY THOSE ACTIVITIES IN WHICH YOU PARTICIPATED FROM GRADE 9 TO PRESENT.
(YOU MAY CHOOSE TO ATTACH A DETAILED ACTIVITY/SPORTS RESUME IN PLACE OF FILLNG OUT THIS SECTION)
NON ATHLETIC ACTIVITIES: (Include work experience, clubs, hobbies, community or service organizations, Naval Reserve Sea Cadets, Scouting, etc.)
Activity
Special Achievement or Awards
Offices Held
Years
SCHOOL ATHLETIC ACTIVITIES:
Activity
KP 2-65 (JANUARY 2012)
12-14693 MARAD part 2 pg 1
Number Varsity Awards
Position
Continued on Reverse
Special Achievements
Years
BIOGRAPHICAL SKETCH/ESSAY: (On a separate sheet of paper, give a biographical sketch of at least 200 words. You must include your reasons for wishing to attend the Academy,
a discussion of your curriculum preference, the development of your career interest as a result of your high school classes, hobbies and activities, including any sailing experience,
seamanʼs experience, and/or military experience. You must also state your understanding and willingness to accept the service obligation upon graduation (U.S. candidates only).
Have you ever visited the Academy?
Yes
No
Plan To Visit (Date) __________________________________________________________
Indicate below the person(s) with whom the Admissions Office may disclose information regarding your candidacy.
Yes
No
Nominating Authority
Yes
No
Parents/Guardian/Other Relative (List Name) ___________________________________________________________________
Yes
No
School Counselor/Principal/Other School Official (List Name) ___________________________________________________________________
Other (Identify) ____________________________________________________
CERTIFICATION OF APPLICANT:
I understand that if I am appointed, after reporting to the Academy to begin the program, I must sign a Service Obligation Contract as set forth in
the current official catalog.
I certify that the statements of dates, place of birth, citizenship, and all other information contained on Parts I and II of this application, are true and
correct to the best of my knowledge. Knowingly providing false information may result in forfeiture of appointment to the Academy.
Signature of Applicant
Date
CERTIFICATION AND CONSENT OF PARENT/GUARDIAN
(Not required if applicant has reached majority age of consent under the laws of his/her State of residence.)
I hereby consent to my son, daughter or wardʼs appointment as a Midshipman to the U.S. Merchant Marine Academy should he/she become
entitled to such appointment. I am aware and in agreement with their mandatory obligation to serve in the U.S. Merchant Marine and to seek and
accept, if tendered, a commission in an armed force reserve unit as set forth in the current catalog.
I certify that the statements of dates, place of birth, citizenship, and all other information contained on Parts I and II of this application, are true and
correct to the best of my knowledge. Knowingly providing false information may result in forfeiture of appointment to the Academy.
Signature of Parent or Guardian
Date
APPLICATION DEADLINE IS MARCH 1
An Appointment will not be considered unless Parts 1 and 3 and the Biographical Essay described above are also completed and received by the above deadline.
Privacy Act Statement
In accordance with 5 USC 552a(e)(3), the following information is provided to you when supplying personal information to the Maritime Administration.
1. Authority which authorized the solicitation of the information: 46 App. USC 1295b and 1295g.
2. Principal purpose(s) for which information is intended to be used: The information is used to evaluate each applicant for an appointment to the
U.S. Merchant Marine Academy.
3. The routine uses which may be made of the information: As background information on applicants for the selection process. To contact the applicant.
The social security number is a basic identifier.
4. Whether or not disclosure of such information is mandatory or voluntary (required by law or optional) and the effects on the individual, if any, of not
providing all or any part of the requested information: Disclosure of the information is voluntary, but the applicant will not be considered further if all
information is not provided.
This collection of information is required to obtain benefits and will be used to determine the eligibility of respondents for admission to the U.S. Merchant Marine Academy. Public
reporting burden is estimated to average five hours 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. The U.S. Merchant Marine Academy does not consult or discuss any information with anyone not
expressly designated by the candidate. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this collection is 2133-0010. Send comments regarding this burden estimate or any other aspect of
this information collection to the Maritime Administration, Office of Management and Administrative Services, 1200 New Jersey Avenue, SE, Room W28-302, Washington, DC 20590.
KP 2-65 (JANUARY 2012)
12-14693 MARAD part 2 pg 2
Continued on Reverse
---OMB No. 2133-0010
U.S. Merchant Marine Academy,
300 Steamboat Road, Kings Point, New York 11024-1699
CANDIDATE APPLICATION — PART 3
STATE OF RESIDENCE
APPLICANT NAME: (Last, First, Middle, and Suffix (Jr., Sr., II, III, IV))
THE APPLICANT COMPLETES ONLY NAME AND SOCIAL SECURITY NUMBER
SOCIAL SECURITY NO.
THE REMAINDER OF THIS FORM IS TO BE COMPLETED BY SCHOOL OFFICIAL(S):
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INSTRUCTIONS: The Student named above is applying for admission to the U.S. Merchant Marine Academy. Please complete this form,
Part III of the studentʼs application, as accurately as possible. The Academy requires the following information as part of the application
review process:
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4. A written evaluation of applicant (see reverse side).
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5. Copy of your School Profile.
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1. Most current transcript, showing all courses taken and completed to date, as well as all courses currently in progress.
2. All standardized test scores (SAT and/or ACT) from tests taken to date.
3. Applicantʼs rank in class. If your school does not rank, you should indicate which decile the applicant falls into (for example, 1st decile for
students in the top 10% of their class, 2nd decile for students in the top 20%, etc.).
IMPORTANT: Please submit this information immediately. Failure to return all materials to the
Admissions office in a timely manner could adversely affect this applicantʼs prospect for an
Appointment to the Academy.
Please provide the following information:
High School CEEB/ACT Code Number: _____________________________ What percentage of your graduates attend 4-year colleges? ____________%
Does your school require an entrance examination?
Yes
No
If “Yes”, what percentage of applicantʼs are admitted? ______________%
High School Name
School Telephone Number
School Address
Applicantʼs Cumulative GPA
Year of Graduation
RANK IN CLASS: (If not available, approximate to nearest tenth from top)
o
Exactly
o Approximately
Rank From Top
Number of Students
Indicate how grade point average and rank in class were determined. (If not described in your enclosed school profile):
OTHER (Additional information which may be significant in considering this applicant)
Name and Title (Please Print or Type)
KP 2-65 (JANUARY 2012)
12-14693 MARAD part 3 pg 1
Signature
Continued on Reverse
Date
INSTRUCTIONS FOR THE SCHOOL OFFICIAL: Please evaluate the following statements concerning this applicant. Mark only one choice for each statement. You are asked to
choose the rating that best describes the applicant in relation to his/her peers.
4. Influence
o
o
o
o
5. Concern for Others
6. Responsibility
7. Integrity
8. Emotional Stability
o
o
o
o
bs
er
ve
d
No
tO
o
o
o
o
Av
er
ag
e
o
o
o
o
Be
lo
w
o
o
o
o
io
r
No
tO
o
o
o
o
Av
er
ag
e
bs
er
ve
d
Av
er
ag
e
Be
lo
w
Av
er
ag
e
Av
er
ag
e
o
o
o
o
Av
er
ag
e
3. Initiative
o
o
o
o
Ab
ov
e
2. Industry
Su
pe
r
o
o
o
o
1. Motivation
Ab
ov
e
Su
pe
r
io
r
Your confidentiality with regard to your responses is assured. Your identity as the source of information relating to this applicant will not be disclosed.
o
o
o
o
REMARKS: Please provide a letter of recommendation containing your professional assessment regarding this applicantʼs ability to perform at a service academy and attach it to this
part of the .application. You are assured of confidentiality regarding your comments. At least two (2) additional assessments from other administrators, faculty and/or coaches, who are
familiar with the applicant, are required. Thank you for your assistance.
NAME AND TITLE OF EVALUATOR (Please Print or Type)
Signature of Evaluator
Date
CHECKLIST: Please use this checklist to assure that all required information is included with this Form:
Student Transcript
Standardized Test (SAT/ACT) Scores
Rank in Class or Equivalent (mandatory)
At Least Three (3) Letters of Recommendation
School Profile
Privacy Act Statement
In accordance with 5 USC 552a(e)(3), the following information is provided to you when supplying personal information to the Maritime Administration.
1. Authority which authorized the solicitation of the information: 46 App. USC 1295b and 1295g.
2. Principal purpose(s) for which information is intended to be used: The information is used to evaluate each applicant for an appointment to the
U.S. Merchant Marine Academy.
3. The routine uses which may be made of the information: As background information on applicants for the selection process. To contact the applicant.
The social security number is a basic identifier.
4. Whether or not disclosure of such information is mandatory or voluntary (required by law or optional) and the effects on the individual, if any, of not
providing all or any part of the requested information: Disclosure of the information is voluntary, but the applicant will not be considered further if all
information is not provided.
This collection of information is required to obtain benefits and will be used to determine the eligibility of respondents for admission to the U.S. Merchant Marine Academy. Public
reporting burden is estimated to average five hours 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. The U.S. Merchant Marine Academy does not consult or discuss any information with anyone not
expressly designated by the candidate. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. The OMB control number for this collection is 2133-0010. Send comments regarding this burden estimate or any other aspect of
this information collection to the Maritime Administration, Office of Management and Administrative Services, 1200 New Jersey Avenue, SE, Room W28-302, Washington, DC 20590.
PLEASE MAIL COMPLETED FORM, WITH ATTACHMENT(S), TO: Director of Admissions
U.S. Merchant Marine Academy
300 Steamboat Road, Wiley Hall
Kings Point, NY 11024-1699
KP 2-65 (JANUARY 2012)
12-14693 MARAD part 3 pg 2
Continued on Reverse
| File Type | application/pdf |
| File Modified | 2018-04-13 |
| File Created | 2012-02-22 |