Fleet Hometown Release Form - United States Naval Academy

➤Print in ink or type
Fleet Home Town News Release
2.Command Releasing Authority:
1. From:
Print Name
United States Naval Academy
121 Blake Road
Annapolis, MD 21402-5000
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
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.
I certify that the information provided is correct and I have no objection to its publication.
USNA PYA 5724/3 (2-00)