Service Academy Nomination | U.S. Representative Jack Bergman

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cellspacing="0" width="100%"> <tr> <td id="ctl00_ContentCell">The honor of attending a service academy comes with the obligation and commitment to serve in the military for a minimum of five years upon graduation.<br /> <br /> Members of Congress may nominate candidates for appointment to four of the five U.S. service academies: <a href="http://www.usma.edu/SitePages/Home.aspx">U.S. Military Academy</a> (USMA), West Point, NY; the <a href="https://www.usna.edu/homepage.php">U.S. Naval Academy</a> (USNA), Annapolis, MD; the <a href="http://www.usafa.af.mil/">U.S. Air Force Academy </a>(USAFA), Colorado Springs, CO; and the <a href="https://www.usmma.edu/">U.S. Merchant Marine Academy</a> (USMMA), Kings Point, NY. The fifth service academy, the <a href="http://cga.edu/">U.S. Coast Guard Academy</a> (USCGA), New London, CT, does not require a congressional nomination for appointment.<br /> <br /> Each Member may nominate up to ten individuals for each vacant academy slot allotted to our district. To request a Military Academy Nomination from our office, please complete the form below. This form must be submitted no later than the first week in October of your Senior year. Best wishes to you as you pursue your goal of attending one of the U.S. Service Academies and serving our country.<br /> <br /> <strong>Required fields are followed by <abbr title="required" class="req">*</abbr>.</strong> <form method="post" action="./" onsubmit="javascript:return WebForm_OnSubmit();" id="aspnetForm" class="sanform"> <div class="aspNetHidden"> <input type="hidden" name="__EVENTTARGET" id="__EVENTTARGET" value="" /> <input type="hidden" name="__EVENTARGUMENT" id="__EVENTARGUMENT" value="" /> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" 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/> </div> <div id="ctl00_ctl14_formPanel"> <div class="middlecopy"> <div id="ctl00_ctl14_valSum" class="formFieldError" style="display:none;"> </div> <fieldset class="formfield-contact"> <legend>Your Contact Information</legend> <div class="formfield fs-prefix"> <label class="formheader" for="ctl00_ctl14_Prefix"> Prefix </label> <input name="ctl00$ctl14$Prefix" type="text" id="ctl00_ctl14_Prefix" class="formsingleline prefix" /> </div> <div class="formfield fs-first-name"> <label class="formheader" for="ctl00_ctl14_FirstName"> First Name <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$FirstName" type="text" id="ctl00_ctl14_FirstName" class="formsingleline fname" required="required" /> <span id="ctl00_ctl14_ctl00" class="formFieldError" role="alert" style="display:none;">First Name is required.</span> </div> <div class="formfield fs-last-name"> <label class="formheader" for="ctl00_ctl14_LastName"> Last Name <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$LastName" type="text" id="ctl00_ctl14_LastName" class="formsingleline lname" required="required" /> <span id="ctl00_ctl14_ctl01" class="formFieldError" role="alert" style="display:none;">Last Name is required.</span> </div> <div class="formfield fs-suffix"> <label class="formheader" for="ctl00_ctl14_Suffix"> Suffix </label> <input name="ctl00$ctl14$Suffix" type="text" id="ctl00_ctl14_Suffix" class="formsingleline suffix" /> </div> <div class="formfield fs-email-address"> <label class="formheader" for="ctl00_ctl14_EmailAddress"> Email Address <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$EmailAddress" id="ctl00_ctl14_EmailAddress" required="required" type="email" /> <span id="ctl00_ctl14_ctl02" class="formFieldError" role="alert" style="display:none;">Email address is required.</span> <span id="ctl00_ctl14_ctl03" class="formFieldError" role="alert" style="display:none;">Invalid email address.</span> </div> <div class="formfield fs-street"> <label class="formheader" for="ctl00_ctl14_Street"> Street Address <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$Street" type="text" id="ctl00_ctl14_Street" class="formsingleline street" required="required" /> <span id="ctl00_ctl14_ctl04" class="formFieldError" style="display:none;">Street Address is required.</span> </div> <div class="formfield fs-city"> <label class="formheader" for="ctl00_ctl14_City"> City <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$City" type="text" id="ctl00_ctl14_City" class="formsingleline city" required="required" /> <span id="ctl00_ctl14_ctl05" class="formFieldError" role="alert" style="display:none;">City is required.</span> </div> <div class="formfield fs-select fs-state"> <label class="formheader" for="ctl00_ctl14_State"> State <abbr title="required" class="req">*</abbr> </label> <select name="ctl00$ctl14$State" id="ctl00_ctl14_State" class="state"> <option value="AL">AL</option> <option value="AK">AK</option> <option value="AZ">AZ</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option selected="selected" value="DC">DC</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IN">IN</option> <option value="IL">IL</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option> <option value="AA">AA</option> <option value="AE">AE</option> <option value="AP">AP</option> <option value="AS">AS</option> <option value="FM">FM</option> <option value="GU">GU</option> <option value="MH">MH</option> <option value="MP">MP</option> <option value="PR">PR</option> <option value="VI">VI</option> </select> </div> <div class="formfield fs-zip"> <label class="formheader" for="ctl00_ctl14_Zip"> Zip Code <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$Zip" type="text" id="ctl00_ctl14_Zip" class="formsingleline zip" required="required" /> <span id="ctl00_ctl14_ctl06" class="formFieldError" role="alert" style="display:none;">Zip code is required.</span> <span id="ctl00_ctl14_ctl07" class="formFieldError" role="alert" style="display:none;">Zip code has to be a number.</span> </div> <div class="formfield fs-phone-number"> <label class="formheader" for="ctl00_ctl14_Phone"> Phone Number <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$Phone" id="ctl00_ctl14_Phone" class="phone" type="tel" required="required" /> <span id="ctl00_ctl14_ctl08" class="formFieldError" role="alert" style="display:none;">Contact Phone Number is required.</span> <span id="ctl00_ctl14_ctl09" class="formFieldError" role="alert" style="display:none;">Phone number must be 10 digits.</span> </div> <div class="formfield fs-dob"> <label class="formheader" for="ctl00_ctl14_DateOfBirth"> Date of Birth <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$DateOfBirth" type="text" id="ctl00_ctl14_DateOfBirth" class="datepicker-birth" required="required" /> <span id="ctl00_ctl14_ctl10" class="formFieldError" role="alert" style="display:none;">Date of Birth is required.</span> </div> <div class="formfield fs-gender"> <label class="formheader" for="ctl00_ctl14_Gender"> Gender <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$Gender" type="text" id="ctl00_ctl14_Gender" required="required" /> <span id="ctl00_ctl14_ctl11" class="formFieldError" role="alert" style="display:none;">Gender is required.</span> </div> <div class="formfield fs-radio fs-citizen"> <legend class="formheader" for="ctl00_ctl14_USCitizen"> US Citizen <abbr title="required" class="req">*</abbr> </legend> <span id="ctl00_ctl14_USCitizen"><input id="ctl00_ctl14_USCitizen_0" type="radio" name="ctl00$ctl14$USCitizen" value="Yes" /><label for="ctl00_ctl14_USCitizen_0">Yes</label><br /><input id="ctl00_ctl14_USCitizen_1" type="radio" name="ctl00$ctl14$USCitizen" value="No" /><label for="ctl00_ctl14_USCitizen_1">No</label></span> <span id="ctl00_ctl14_ctl12" class="formFieldError" role="alert" style="display:none;">Citizenship status is required.</span> </div> <div class="formfield fs-country"> <label class="formheader" for="ctl00_ctl14_CountryOfCitizenship"> Country of Citizenship </label> <input name="ctl00$ctl14$CountryOfCitizenship" type="text" id="ctl00_ctl14_CountryOfCitizenship" /> </div> </fieldset> <fieldset class="formfield-guardian"> <legend>Parent/Guardian Information</legend> <div class="formfield fs-parent-name"> <label class="formheader" for="ctl00_ctl14_GuardiansName"> Parent/Guardian Name <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$GuardiansName" type="text" id="ctl00_ctl14_GuardiansName" required="required" /> <span id="ctl00_ctl14_ctl13" class="formFieldError" role="alert" style="display:none;">Parent/Guardian Name is required.</span> </div> <div class="formfield fs-street-guardian"> <label class="formheader" for="ctl00_ctl14_GuardiansStreet"> Street Address <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$GuardiansStreet" type="text" id="ctl00_ctl14_GuardiansStreet" class="formsingleline street" required="required" /> <span id="ctl00_ctl14_ctl14" class="formFieldError" role="alert" style="display:none;"> Parent/Guardian Street Address is required.</span> </div> <div class="formfield fs-city-guardian"> <label class="formheader" for="ctl00_ctl14_GuardiansCity"> City <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$GuardiansCity" type="text" id="ctl00_ctl14_GuardiansCity" class="formsingleline city" required="required" /> <span id="ctl00_ctl14_ctl15" class="formFieldError" role="alert" style="display:none;">Parent/Guardian City is required.</span> </div> <div class="formfield fs-select fs-state"> <label class="formheader" for="ctl00_ctl14_GuardiansState"> State <abbr title="required" class="req">*</abbr> </label> <select name="ctl00$ctl14$GuardiansState" id="ctl00_ctl14_GuardiansState" class="state"> <option value="AL">AL</option> <option value="AK">AK</option> <option value="AZ">AZ</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option selected="selected" value="DC">DC</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IN">IN</option> <option value="IL">IL</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option> <option value="AA">AA</option> <option value="AE">AE</option> <option value="AP">AP</option> <option value="AS">AS</option> <option value="FM">FM</option> <option value="GU">GU</option> <option value="MH">MH</option> <option value="MP">MP</option> <option value="PR">PR</option> <option value="VI">VI</option> </select> </div> <div class="formfield fs-zip-guardian"> <label class="formheader" for="ctl00_ctl14_GuardiansZip"> Zip Code <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$GuardiansZip" type="text" id="ctl00_ctl14_GuardiansZip" class="formsingleline zip" required="required" /> <span id="ctl00_ctl14_ctl16" class="formFieldError" role="alert" style="display:none;">Parent/Guardian Zip code is required.</span> <span id="ctl00_ctl14_ctl17" class="formFieldError" role="alert" style="display:none;">Parent/Guardian Zip code has to be a number.</span> </div> </fieldset> <fieldset class="formfield-education"> <legend>Education Information</legend> <div class="formfield fs-school-name"> <label class="formheader" for="ctl00_ctl14_HighSchoolName"> High School Name <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$HighSchoolName" type="text" id="ctl00_ctl14_HighSchoolName" required="required" /> <span id="ctl00_ctl14_ctl18" class="formFieldError" role="alert" style="display:none;">High School Name is required.</span> </div> <div class="formfield fs-street-school"> <label class="formheader" for="ctl00_ctl14_HighSchoolStreet"> Street Address <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$HighSchoolStreet" type="text" id="ctl00_ctl14_HighSchoolStreet" class="formsingleline street" required="required" /> <span id="ctl00_ctl14_ctl19" class="formFieldError" style="display:none;">High School Street Address is required.</span> </div> <div class="formfield fs-city-school"> <label class="formheader" for="ctl00_ctl14_HighSchoolCity"> City <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$HighSchoolCity" type="text" id="ctl00_ctl14_HighSchoolCity" class="formsingleline city" required="required" /> <span id="ctl00_ctl14_ctl20" class="formFieldError" role="alert" style="display:none;">High School City is required.</span> </div> <div class="formfield fs-select fs-state"> <label class="formheader" for="ctl00_ctl14_HighSchoolState"> State <abbr title="required" class="req">*</abbr> </label> <select name="ctl00$ctl14$HighSchoolState" id="ctl00_ctl14_HighSchoolState" class="state"> <option value="AL">AL</option> <option value="AK">AK</option> <option value="AZ">AZ</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option selected="selected" value="DC">DC</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IN">IN</option> <option value="IL">IL</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option> <option value="AA">AA</option> <option value="AE">AE</option> <option value="AP">AP</option> <option value="AS">AS</option> <option value="FM">FM</option> <option value="GU">GU</option> <option value="MH">MH</option> <option value="MP">MP</option> <option value="PR">PR</option> <option value="VI">VI</option> </select> </div> <div class="formfield fs-zip-school"> <label class="formheader" for="ctl00_ctl14_HighSchoolZip"> Zip Code <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$HighSchoolZip" type="text" id="ctl00_ctl14_HighSchoolZip" class="formsingleline zip" required="required" /> <span id="ctl00_ctl14_ctl21" class="formFieldError" role="alert" style="display:none;">High School Zip code is required.</span> <span id="ctl00_ctl14_RegularExpressionValidator12" class="formFieldError" role="alert" style="display:none;">High School Zip code has to be a number.</span> </div> <div class="formfield fs-gpa"> <label class="formheader" for="ctl00_ctl14_HighSchoolGpa"> GPA <abbr title="required" class="req">*</abbr> </label> <input name="ctl00$ctl14$HighSchoolGpa" type="text" id="ctl00_ctl14_HighSchoolGpa" required="required" /> <span id="ctl00_ctl14_ctl22" class="formFieldError" role="alert" style="display:none;">High School GPA is required.</span> </div> <div class="formfield fs-class-size"> <label class="formheader" for="ctl00_ctl14_HighSchoolClassSize"> Class Size </label> <input name="ctl00$ctl14$HighSchoolClassSize" type="text" id="ctl00_ctl14_HighSchoolClassSize" /> </div> <div class="formfield fs-rank"> <label class="formheader" for="ctl00_ctl14_HighSchoolRank"> Rank </label> <input name="ctl00$ctl14$HighSchoolRank" type="text" id="ctl00_ctl14_HighSchoolRank" /> </div> <div class="formfield fs-graduation-date"> <label class="formheader" for="ctl00_ctl14_HighSchoolGraduationDate"> Graduation Date </label> <input name="ctl00$ctl14$HighSchoolGraduationDate" type="text" id="ctl00_ctl14_HighSchoolGraduationDate" class="datepicker-grad" /> </div> </fieldset> <fieldset class="formfield-sat"> <legend>SAT Test Scores</legend> <div class="formfield fs-sat-math"> <label class="formheader" for="ctl00_ctl14_SATMath"> Math </label> <input name="ctl00$ctl14$SATMath" type="text" id="ctl00_ctl14_SATMath" /> </div> <div class="formfield fs-sat-writing"> <label class="formheader" for="ctl00_ctl14_SATWriting"> Writing </label> <input name="ctl00$ctl14$SATWriting" type="text" id="ctl00_ctl14_SATWriting" /> </div> <div class="formfield fs-sat-reading"> <label class="formheader" for="ctl00_ctl14_SATCriticalReading"> Critical Reading </label> <input name="ctl00$ctl14$SATCriticalReading" type="text" id="ctl00_ctl14_SATCriticalReading" /> </div> <div class="formfield fs-sat-composite"> <label class="formheader" for="ctl00_ctl14_SATComposite"> Composite </label> <input name="ctl00$ctl14$SATComposite" type="text" id="ctl00_ctl14_SATComposite" /> </div> </fieldset> <fieldset class="formfield-act"> <legend>ACT Test Scores</legend> <div class="formfield fs-act-english"> <label class="formheader" for="ctl00_ctl14_ACTEnglish"> English </label> <input name="ctl00$ctl14$ACTEnglish" type="text" id="ctl00_ctl14_ACTEnglish" /> </div> <div class="formfield fs-act-math"> <label class="formheader" for="ctl00_ctl14_ACTMath"> Math </label> <input name="ctl00$ctl14$ACTMath" type="text" id="ctl00_ctl14_ACTMath" /> </div> <div class="formfield fs-act-reading"> <label class="formheader" for="ctl00_ctl14_ACTReading"> Reading </label> <input name="ctl00$ctl14$ACTReading" type="text" id="ctl00_ctl14_ACTReading" /> </div> <div class="formfield fs-act-science"> <label class="formheader" for="ctl00_ctl14_ACTScience"> Science </label> <input name="ctl00$ctl14$ACTScience" type="text" id="ctl00_ctl14_ACTScience" /> </div> <div class="formfield fs-act-composite"> <label class="formheader" for="ctl00_ctl14_ACTComposite"> Composite </label> <input name="ctl00$ctl14$ACTComposite" type="text" id="ctl00_ctl14_ACTComposite" /> </div> </fieldset> <fieldset class="formfield-academy"> <legend>Academy Information</legend> <div class="formfield fs-select fs-academy-first"> <label class="formheader" for="ctl00_ctl14_FirstPick"> First Pick </label> <select size="1" name="ctl00$ctl14$FirstPick" id="ctl00_ctl14_FirstPick"> <option value=""></option> <option value="U.S. Air Force Academy">U.S. Air Force Academy</option> <option value="U.S. Military Academy">U.S. Military Academy</option> <option value="U.S. Naval Academy">U.S. Naval Academy</option> <option value="U.S. Merchant Marine Academy">U.S. Merchant Marine Academy</option> </select> </div> <div class="formfield fs-select fs-academy-second"> <label class="formheader" for="ctl00_ctl14_SecondPick"> Second Pick </label> <select size="1" name="ctl00$ctl14$SecondPick" id="ctl00_ctl14_SecondPick"> <option value=""></option> <option value="U.S. Air Force Academy">U.S. Air Force Academy</option> <option value="U.S. Military Academy">U.S. Military Academy</option> <option value="U.S. Naval Academy">U.S. Naval Academy</option> <option value="U.S. Merchant Marine Academy">U.S. Merchant Marine Academy</option> </select> </div> <div class="formfield fs-select fs-academy-third"> <label class="formheader" for="ctl00_ctl14_ThirdPick"> Third Pick </label> <select size="1" name="ctl00$ctl14$ThirdPick" id="ctl00_ctl14_ThirdPick"> <option value=""></option> <option value="U.S. Air Force Academy">U.S. Air Force Academy</option> <option value="U.S. Military Academy">U.S. Military Academy</option> <option value="U.S. Naval Academy">U.S. Naval Academy</option> <option value="U.S. Merchant Marine Academy">U.S. Merchant Marine Academy</option> </select> </div> <div class="formfield fs-select fs-academy-fourth"> <label class="formheader" for="ctl00_ctl14_FourthPick"> Fourth Pick </label> <select size="1" name="ctl00$ctl14$FourthPick" id="ctl00_ctl14_FourthPick"> <option value=""></option> <option value="U.S. Air Force Academy">U.S. Air Force Academy</option> <option value="U.S. Military Academy">U.S. Military Academy</option> <option value="U.S. Naval Academy">U.S. Naval Academy</option> <option value="U.S. Merchant Marine Academy">U.S. Merchant Marine Academy</option> </select> </div> <div class="formfield fs-radio fs-devotion"> <legend for="ctl00_ctl14_LifetimeDevotion" class="formheader"> An appointment to the Service Academies is based on a desire by the candidate to devote a lifetime of military service and implies recognition by the appointee of an obligation to the government to devote him / herself to a military career. Are you interested in an appointment on that basis? </legend> <span id="ctl00_ctl14_LifetimeDevotion"><input id="ctl00_ctl14_LifetimeDevotion_0" type="radio" name="ctl00$ctl14$LifetimeDevotion" value="Yes" /><label for="ctl00_ctl14_LifetimeDevotion_0">Yes</label><br /><input id="ctl00_ctl14_LifetimeDevotion_1" type="radio" name="ctl00$ctl14$LifetimeDevotion" value="No" /><label for="ctl00_ctl14_LifetimeDevotion_1">No</label></span> </div> </fieldset> <fieldset class="formfield-additional"> <legend>Additional Information</legend> <div class="formfield fs-textarea fs-extracurriculars"> <label class="formheader" for="ctl00_ctl14_ExtraCurricular"> Extracurricular Activities </label> <textarea name="ctl00$ctl14$ExtraCurricular" rows="10" cols="20" id="ctl00_ctl14_ExtraCurricular"> </textarea> </div> <div class="formfield fs-newspaper"> <label class="formheader" for="ctl00_ctl14_HometownNewspaper"> Name of Hometown Newspaper </label> <input name="ctl00$ctl14$HometownNewspaper" type="text" id="ctl00_ctl14_HometownNewspaper" /> </div> <div class="formfield fs-radio fs-press-name"> <legend class="formheader" for="ctl00_ctl14_IncludeInPressRelease"> Is it ok to use your name in a press release? </legend> <span id="ctl00_ctl14_IncludeInPressRelease"><input id="ctl00_ctl14_IncludeInPressRelease_0" type="radio" name="ctl00$ctl14$IncludeInPressRelease" value="Yes" /><label for="ctl00_ctl14_IncludeInPressRelease_0">Yes</label><br /><input id="ctl00_ctl14_IncludeInPressRelease_1" type="radio" name="ctl00$ctl14$IncludeInPressRelease" value="No" /><label for="ctl00_ctl14_IncludeInPressRelease_1">No</label></span> </div> </fieldset> <input type="hidden" name="ctl00$ctl14$Sf" id="ctl00_ctl14_Sf" value="118a4602-cd75-46f5-9522-7c058d3c154b" /> <script src="https://www.google.com/recaptcha/api.js" async defer></script> <div class="g-recaptcha" data-sitekey="6Le2KP8SAAAAAA38fpHcO6WgjGaZZrtSNyxfzxkm"></div> <noscript> <div> <div style="width: 302px; height: 422px; position: relative;"> <div style="width: 302px; height: 422px; position: absolute;"> <iframe src="https://www.google.com/recaptcha/api/fallback?k=6Le2KP8SAAAAAA38fpHcO6WgjGaZZrtSNyxfzxkm" frameborder="0" scrolling="no" style="width: 302px; height:422px; border-style: none;"> </iframe> </div> </div> <div style="width: 300px; height: 60px; border-style: none; bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px; background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;"> <textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response" style="width: 250px; height: 40px; border: 1px solid #c1c1c1; margin: 10px 25px; padding: 0px; resize: none;" > </textarea> </div> </div> </noscript> <br /> <input type="submit" name="ctl00$ctl14$ctl23" value="Submit" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("ctl00$ctl14$ctl23", "", true, "", "", false, false))" /> </div> </div> <script type="text/javascript">window.jQuery || document.write('<script src="/sysjs/jquery.latest.min.js"><\/script>')</script> <script type="text/javascript">window.jQuery.ui || document.write('<script src="/sysjs/jquery-ui.latest.min.js"><\/script>')</script> <link rel="stylesheet" href="/styles/jquery-ui.latest.css" /> <script src="/sysjs/jquery.maskedinput.min.js"></script> <script> jQuery(document).ready(function () { jQuery('.datepicker-birth').datepicker({ changeMonth: true, changeYear: true, minDate: '-27y', maxDate: '-16y' }); jQuery('.datepicker-grad').datepicker({ changeMonth: true, changeYear: true, minDate: '-2y', maxDate: '+5y' }); jQuery('.phone').mask('(999) 999-9999'); }); </script> <script type="text/javascript"> //<![CDATA[ var Page_ValidationSummaries = new Array(document.getElementById("ctl00_ctl14_valSum")); var Page_Validators = new Array(document.getElementById("ctl00_ctl14_ctl00"), document.getElementById("ctl00_ctl14_ctl01"), document.getElementById("ctl00_ctl14_ctl02"), document.getElementById("ctl00_ctl14_ctl03"), document.getElementById("ctl00_ctl14_ctl04"), document.getElementById("ctl00_ctl14_ctl05"), document.getElementById("ctl00_ctl14_ctl06"), document.getElementById("ctl00_ctl14_ctl07"), document.getElementById("ctl00_ctl14_ctl08"), document.getElementById("ctl00_ctl14_ctl09"), document.getElementById("ctl00_ctl14_ctl10"), document.getElementById("ctl00_ctl14_ctl11"), document.getElementById("ctl00_ctl14_ctl12"), document.getElementById("ctl00_ctl14_ctl13"), document.getElementById("ctl00_ctl14_ctl14"), document.getElementById("ctl00_ctl14_ctl15"), document.getElementById("ctl00_ctl14_ctl16"), document.getElementById("ctl00_ctl14_ctl17"), document.getElementById("ctl00_ctl14_ctl18"), document.getElementById("ctl00_ctl14_ctl19"), document.getElementById("ctl00_ctl14_ctl20"), document.getElementById("ctl00_ctl14_ctl21"), document.getElementById("ctl00_ctl14_RegularExpressionValidator12"), document.getElementById("ctl00_ctl14_ctl22")); //]]> </script> <script type="text/javascript"> //<![CDATA[ var ctl00_ctl14_valSum = document.all ? document.all["ctl00_ctl14_valSum"] : document.getElementById("ctl00_ctl14_valSum"); ctl00_ctl14_valSum.headertext = "You must enter a value in the following fields:"; var ctl00_ctl14_ctl00 = document.all ? document.all["ctl00_ctl14_ctl00"] : document.getElementById("ctl00_ctl14_ctl00"); ctl00_ctl14_ctl00.controltovalidate = "ctl00_ctl14_FirstName"; ctl00_ctl14_ctl00.errormessage = "First Name is required."; ctl00_ctl14_ctl00.display = "Dynamic"; ctl00_ctl14_ctl00.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl00.initialvalue = ""; var ctl00_ctl14_ctl01 = document.all ? document.all["ctl00_ctl14_ctl01"] : document.getElementById("ctl00_ctl14_ctl01"); ctl00_ctl14_ctl01.controltovalidate = "ctl00_ctl14_LastName"; ctl00_ctl14_ctl01.errormessage = "Last Name is required."; ctl00_ctl14_ctl01.display = "Dynamic"; ctl00_ctl14_ctl01.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl01.initialvalue = ""; var ctl00_ctl14_ctl02 = document.all ? document.all["ctl00_ctl14_ctl02"] : document.getElementById("ctl00_ctl14_ctl02"); ctl00_ctl14_ctl02.controltovalidate = "ctl00_ctl14_EmailAddress"; ctl00_ctl14_ctl02.errormessage = "Email address is required."; ctl00_ctl14_ctl02.display = "Dynamic"; ctl00_ctl14_ctl02.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl02.initialvalue = ""; var ctl00_ctl14_ctl03 = document.all ? document.all["ctl00_ctl14_ctl03"] : document.getElementById("ctl00_ctl14_ctl03"); ctl00_ctl14_ctl03.controltovalidate = "ctl00_ctl14_EmailAddress"; ctl00_ctl14_ctl03.errormessage = "Invalid email address."; ctl00_ctl14_ctl03.display = "Dynamic"; ctl00_ctl14_ctl03.evaluationfunction = "RegularExpressionValidatorEvaluateIsValid"; ctl00_ctl14_ctl03.validationexpression = "^\\w+([-+.\']\\w+)*@\\w+([-.]\\w+)*\\.\\w+([-.]\\w+)*$"; var ctl00_ctl14_ctl04 = document.all ? document.all["ctl00_ctl14_ctl04"] : document.getElementById("ctl00_ctl14_ctl04"); ctl00_ctl14_ctl04.controltovalidate = "ctl00_ctl14_Street"; ctl00_ctl14_ctl04.errormessage = "Street Address is required."; ctl00_ctl14_ctl04.display = "Dynamic"; ctl00_ctl14_ctl04.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl04.initialvalue = ""; var ctl00_ctl14_ctl05 = document.all ? document.all["ctl00_ctl14_ctl05"] : document.getElementById("ctl00_ctl14_ctl05"); ctl00_ctl14_ctl05.controltovalidate = "ctl00_ctl14_City"; ctl00_ctl14_ctl05.errormessage = "City is required."; ctl00_ctl14_ctl05.display = "Dynamic"; ctl00_ctl14_ctl05.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl05.initialvalue = ""; var ctl00_ctl14_ctl06 = document.all ? document.all["ctl00_ctl14_ctl06"] : document.getElementById("ctl00_ctl14_ctl06"); ctl00_ctl14_ctl06.controltovalidate = "ctl00_ctl14_Zip"; ctl00_ctl14_ctl06.errormessage = "Zip code is required."; ctl00_ctl14_ctl06.display = "Dynamic"; ctl00_ctl14_ctl06.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl06.initialvalue = ""; var ctl00_ctl14_ctl07 = document.all ? document.all["ctl00_ctl14_ctl07"] : document.getElementById("ctl00_ctl14_ctl07"); ctl00_ctl14_ctl07.controltovalidate = "ctl00_ctl14_Zip"; ctl00_ctl14_ctl07.errormessage = "Zip code has to be a number."; ctl00_ctl14_ctl07.display = "Dynamic"; ctl00_ctl14_ctl07.evaluationfunction = "RegularExpressionValidatorEvaluateIsValid"; ctl00_ctl14_ctl07.validationexpression = "[\\d\\s-]+"; var ctl00_ctl14_ctl08 = document.all ? document.all["ctl00_ctl14_ctl08"] : document.getElementById("ctl00_ctl14_ctl08"); ctl00_ctl14_ctl08.controltovalidate = "ctl00_ctl14_Phone"; ctl00_ctl14_ctl08.errormessage = "Contact Phone Number is required."; ctl00_ctl14_ctl08.display = "Dynamic"; ctl00_ctl14_ctl08.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl08.initialvalue = ""; var ctl00_ctl14_ctl09 = document.all ? document.all["ctl00_ctl14_ctl09"] : document.getElementById("ctl00_ctl14_ctl09"); ctl00_ctl14_ctl09.controltovalidate = "ctl00_ctl14_Phone"; ctl00_ctl14_ctl09.errormessage = "Phone number must be 10 digits."; ctl00_ctl14_ctl09.display = "Dynamic"; ctl00_ctl14_ctl09.evaluationfunction = "RegularExpressionValidatorEvaluateIsValid"; ctl00_ctl14_ctl09.validationexpression = "^(\\D*\\d){10}\\D*$"; var ctl00_ctl14_ctl10 = document.all ? document.all["ctl00_ctl14_ctl10"] : document.getElementById("ctl00_ctl14_ctl10"); ctl00_ctl14_ctl10.controltovalidate = "ctl00_ctl14_DateOfBirth"; ctl00_ctl14_ctl10.errormessage = "Date of Birth is required."; ctl00_ctl14_ctl10.display = "Dynamic"; ctl00_ctl14_ctl10.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl10.initialvalue = ""; var ctl00_ctl14_ctl11 = document.all ? document.all["ctl00_ctl14_ctl11"] : document.getElementById("ctl00_ctl14_ctl11"); ctl00_ctl14_ctl11.controltovalidate = "ctl00_ctl14_Gender"; ctl00_ctl14_ctl11.errormessage = "Gender is required."; ctl00_ctl14_ctl11.display = "Dynamic"; ctl00_ctl14_ctl11.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl11.initialvalue = ""; var ctl00_ctl14_ctl12 = document.all ? document.all["ctl00_ctl14_ctl12"] : document.getElementById("ctl00_ctl14_ctl12"); ctl00_ctl14_ctl12.controltovalidate = "ctl00_ctl14_USCitizen"; ctl00_ctl14_ctl12.errormessage = "Citizenship status is required."; ctl00_ctl14_ctl12.display = "Dynamic"; ctl00_ctl14_ctl12.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl12.initialvalue = ""; var ctl00_ctl14_ctl13 = document.all ? document.all["ctl00_ctl14_ctl13"] : document.getElementById("ctl00_ctl14_ctl13"); ctl00_ctl14_ctl13.controltovalidate = "ctl00_ctl14_GuardiansName"; ctl00_ctl14_ctl13.errormessage = "Parent/Guardian Name is required."; ctl00_ctl14_ctl13.display = "Dynamic"; ctl00_ctl14_ctl13.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl13.initialvalue = ""; var ctl00_ctl14_ctl14 = document.all ? document.all["ctl00_ctl14_ctl14"] : document.getElementById("ctl00_ctl14_ctl14"); ctl00_ctl14_ctl14.controltovalidate = "ctl00_ctl14_GuardiansStreet"; ctl00_ctl14_ctl14.errormessage = " Parent/Guardian Street Address is required."; ctl00_ctl14_ctl14.display = "Dynamic"; ctl00_ctl14_ctl14.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl14.initialvalue = ""; var ctl00_ctl14_ctl15 = document.all ? document.all["ctl00_ctl14_ctl15"] : document.getElementById("ctl00_ctl14_ctl15"); ctl00_ctl14_ctl15.controltovalidate = "ctl00_ctl14_GuardiansCity"; ctl00_ctl14_ctl15.errormessage = "Parent/Guardian City is required."; ctl00_ctl14_ctl15.display = "Dynamic"; ctl00_ctl14_ctl15.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl15.initialvalue = ""; var ctl00_ctl14_ctl16 = document.all ? document.all["ctl00_ctl14_ctl16"] : document.getElementById("ctl00_ctl14_ctl16"); ctl00_ctl14_ctl16.controltovalidate = "ctl00_ctl14_GuardiansZip"; ctl00_ctl14_ctl16.errormessage = "Parent/Guardian Zip code is required."; ctl00_ctl14_ctl16.display = "Dynamic"; ctl00_ctl14_ctl16.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl16.initialvalue = ""; var ctl00_ctl14_ctl17 = document.all ? document.all["ctl00_ctl14_ctl17"] : document.getElementById("ctl00_ctl14_ctl17"); ctl00_ctl14_ctl17.controltovalidate = "ctl00_ctl14_GuardiansZip"; ctl00_ctl14_ctl17.errormessage = "Parent/Guardian Zip code has to be a number."; ctl00_ctl14_ctl17.display = "Dynamic"; ctl00_ctl14_ctl17.evaluationfunction = "RegularExpressionValidatorEvaluateIsValid"; ctl00_ctl14_ctl17.validationexpression = "[\\d\\s-]+"; var ctl00_ctl14_ctl18 = document.all ? document.all["ctl00_ctl14_ctl18"] : document.getElementById("ctl00_ctl14_ctl18"); ctl00_ctl14_ctl18.controltovalidate = "ctl00_ctl14_HighSchoolName"; ctl00_ctl14_ctl18.errormessage = "High School Name is required."; ctl00_ctl14_ctl18.display = "Dynamic"; ctl00_ctl14_ctl18.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl18.initialvalue = ""; var ctl00_ctl14_ctl19 = document.all ? document.all["ctl00_ctl14_ctl19"] : document.getElementById("ctl00_ctl14_ctl19"); ctl00_ctl14_ctl19.controltovalidate = "ctl00_ctl14_HighSchoolStreet"; ctl00_ctl14_ctl19.errormessage = "High School Street Address is required."; ctl00_ctl14_ctl19.display = "Dynamic"; ctl00_ctl14_ctl19.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl19.initialvalue = ""; var ctl00_ctl14_ctl20 = document.all ? document.all["ctl00_ctl14_ctl20"] : document.getElementById("ctl00_ctl14_ctl20"); ctl00_ctl14_ctl20.controltovalidate = "ctl00_ctl14_HighSchoolCity"; ctl00_ctl14_ctl20.errormessage = "High School City is required."; ctl00_ctl14_ctl20.display = "Dynamic"; ctl00_ctl14_ctl20.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl20.initialvalue = ""; var ctl00_ctl14_ctl21 = document.all ? document.all["ctl00_ctl14_ctl21"] : document.getElementById("ctl00_ctl14_ctl21"); ctl00_ctl14_ctl21.controltovalidate = "ctl00_ctl14_HighSchoolZip"; ctl00_ctl14_ctl21.errormessage = "High School Zip code is required."; ctl00_ctl14_ctl21.display = "Dynamic"; ctl00_ctl14_ctl21.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl21.initialvalue = ""; var ctl00_ctl14_RegularExpressionValidator12 = document.all ? document.all["ctl00_ctl14_RegularExpressionValidator12"] : document.getElementById("ctl00_ctl14_RegularExpressionValidator12"); ctl00_ctl14_RegularExpressionValidator12.controltovalidate = "ctl00_ctl14_HighSchoolZip"; ctl00_ctl14_RegularExpressionValidator12.errormessage = "High School Zip code has to be a number."; ctl00_ctl14_RegularExpressionValidator12.display = "Dynamic"; ctl00_ctl14_RegularExpressionValidator12.evaluationfunction = "RegularExpressionValidatorEvaluateIsValid"; ctl00_ctl14_RegularExpressionValidator12.validationexpression = "[\\d\\s-]+"; var ctl00_ctl14_ctl22 = document.all ? document.all["ctl00_ctl14_ctl22"] : document.getElementById("ctl00_ctl14_ctl22"); ctl00_ctl14_ctl22.controltovalidate = "ctl00_ctl14_HighSchoolGpa"; ctl00_ctl14_ctl22.errormessage = "High School GPA is required."; ctl00_ctl14_ctl22.display = "Dynamic"; ctl00_ctl14_ctl22.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid"; ctl00_ctl14_ctl22.initialvalue = ""; //]]> </script> <script type="text/javascript"> //<![CDATA[ var Page_ValidationActive = false; if (typeof(ValidatorOnLoad) == "function") { ValidatorOnLoad(); } function ValidatorOnSubmit() { if (Page_ValidationActive) { return ValidatorCommonOnSubmit(); } else { return true; } } //]]> </script> </form> </td> </tr> </table> </div> </div> </div> <section aria-label="Sidebar" id="sidebar"> <div class="signup-box"> <h2><span class="text">Stay</span> Connected</h2> <p>Enter your email address to get the latest updates straight to your inbox.</p> <form class="signup-form" action="/forms/emailsignup"> <div class="row"><label class="hidden" for="email3">Email Address</label><input type="email" placeholder="Enter Email Address" name="email" id="email3"></div> <div class="row"><button type="submit">Submit</button></div> </form> </div> </section> </div> </div> <div class="connect-block" style="background:url('/images/connect.jpg'); background-position:50% 50%; background-size:cover; background-repeat:no-repeat; min-height:300px;"> <div class="holder"> <h2><span class="text">Stay</span> Connected</h2> <p>Use the form below to sign up for my newsletter and get the latest news and updates directly to your inbox.</p> <div class="content-hold"> <form class="signup-form" action="/forms/emailsignup"> <div class="input-wrap"> <label class="hidden" for="email4">Email Address</label> <input type="email" class="email" id="email4" name="email" required="required" placeholder="Enter Email Address"> </div> <button type="submit">Sign up</button> </form> <ul class="icons-list"> <li><a href="https://www.facebook.com/RepJackBergman/" target="_blank"><span class="icon-facebook-circle"><span class="hidden">Facebook</span></span></a></li> <li><a href="https://twitter.com/RepJackBergman" target="_blank"><span class="icon-twitter-circle"><span class="hidden">Twitter</span></span></a></li> <li><a href="https://www.instagram.com/RepJackBergman/" target="_blank"><span class="icon-instagram-circle"><span class="hidden">Instagram</span></span></a></li>  </ul> </div> </div> </div> <div class="contact-block js-locations-holder"> <div class="holder"> <h2><span class="text">Office</span> Locations</h2> <ul class="offices"> <li class="active" data-location="[38.8866854,-77.0090121]"> <a class="open" href="#">Washington Office</a> <div class="slide"> <address><a href="https://www.google.com/maps?daddr=38.8866854,-77.0090121" target="_blank">566 Cannon HOB<br /> Washington, DC 20515</a><br /> Phone: <a href="tel:2022254735" class="tel">202-225-4735</a></address> </div> </li> <li data-location="[44.7066439,-85.598406]"> <a class="open" href="#">Traverse City Office</a> <div class="slide"> <address><a href="https://www.google.com/maps?daddr=44.7066439,-85.598406" target="_blank">1396 Douglas Drive, Suite 22B<br /> Traverse City, MI 49696</a><br /> Phone: <a href="tel:2319447633" class="tel">231-944-7633</a></address> </div> </li> <li data-location="[46.3518694,-87.3912084]"> <a class="open" href="#">Gwinn Office</a> <div class="slide"> <address><a href="https://www.google.com/maps?daddr=46.3518694,-87.3912084" target="_blank">125 G Avenue, Suite B-119<br /> Gwinn, MI 49841</a><br /> Phone: <a href="tel:9062732227">906-273-2227</a></address> </div> </li> <li data-location="[45.9632835,-86.2598917]"> <a class="open" href="#">Manistique Office</a> <div class="slide"> <address><a href="https://www.google.com/maps?daddr=45.9632835,-86.2598917" target="_blank">7676W County Road 442, Suite B<br /> Manistique, MI 49854</a><br /> Phone: <a href="tel:9062864191">906-286-4191</a></address> </div> </li> <li data-location="[44.4198419,-83.3718261]"> <a class="open" href="#">Oscoda</a> <div class="slide"> <address><a href="https://www.google.com/maps?daddr=44.4198419,-83.3718261" target="_blank"><span style="display:none;">221 N State St<br /> </span> P.O. 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Service Academy Nomination | U.S. Representative Jack Bergman