➤Print in ink or type Fleet Home Town News Release 2.Command Releasing Authority: 1. From: Print Name Signature Superintendent United States Naval Academy 121 Blake Road Annapolis, MD 21402-5000 3. RUC/UIC/OPFAC 4. Branch of service Active duty, USN 6. Your first, MI, last name 5. Date of event address (number and street) United States Naval Academy city, state, zip Annapolis, MD 21402 Rank in Brigade 00161 duty phone: 410-293-2291 7. social security number 8. sex: M / F Your living parents, or if guardians or other relatives, show relationship -- if military, include rank/service 9. Your father’s first, MI, last name address (number and street) city, state, zip 10. Your mother’s first, MI, last name address (number and street) Same as Block 9 ❏ city, state, zip 11. High School - Complete name 12. Professional duties in Brigade City, State, Zip ❏ ❏ Fall Semester Spring Semester Year graduated 13. Earning a bachelor of science degree with a major in: 14. Special academic awards: ❏ Fall Semester ❏ Spring Semester ❏ Superintendent’s List—QPR* of 3.4 +, no D’s, F’s or I’s; A in military performance, A in conduct, A or B in P.E. ❏ Dean’s List—QPR* of 3.4 +, no D’s, F’s or I’s; B in military performance, B in conduct, A, B or C in P.E. ❏ Commandant’s List—QPR* of 2.9 +; B in military performance, A in conduct, B in P.E. 15. Academic Honors ❏ VGEP (Voluntary Graduate Education Program); * Quality Point Ratio ❏ Trident Scholar; ❏ Honors in major/Honor Society; ❏ Rhodes Scholar 16. Military awards Privacy Act Statement: Authority: 5 U.S.C. 301, Exec. Order 9397. Purpose: to prepare news releases for use by civilian news media to recognize the achievements of service members. SSN is for internal FHTNC use only and is not released. Routine use: Information will be released to civilian news media. Once published, information is considered “public domain.” Disclosure is voluntary. Failure to provide complete information only results in no news release being made. 17. I certify that the information provided is correct and I have no objection to its publication. ➤ Signature USNA PYA 5724/3 (2-00) Date