Fillable Printable Selective Service Registration Form - California

Selective Service Registration Form - California

SELECTIVE SERVICE SYSTEM REGISTRATION FORM

or complete this form

SSS FORM 1 (JAN 12) OMB APPROVAL 3240-0002

SIGNATURE

INT

I AFFIRM THE FOREGOING STATEMENTS ARE TRUE

TODAY’S DATE: (MM-DD-YYYY)

CURRENT MAILING ADDRESS: STREET ADDRESS & APARTMENT NUMBER

CITY STATE ZIP CODE

LAST NAME

FIRST NAME & MIDDLE NAME

OTHER SUFFIXSUFFIX: (Mark with “X”)

JR III

DATE OF BIRTH: (MM-DD-YYYY) SOCIAL SECURITY NUMBERSEX: (Mark with “X”)

Male Female

PRINT ONLY IN BLACK INK AND IN CAPITAL LETTERS ONLY

DO NOT WRITE IN THIS SPACE

We estimate the public reporting burden for this collection will vary from two minutes per response, including time for reviewing

instructions, searching existing data sources, gathering data, and completing and reviewing the information. Send comments

regarding the burden statement or any other aspects of the collection of information, including suggestions for reducing this

burden to: Selective Service System, SSS Forms Ofﬁcer (3240-0002), Arlington, VA 22209-2425. The OMB control number

3240-0002, is currently valid. Persons are not required to respond to this collection unless it displays a valid OMB control number.

AGENCY USE

Mail this form to:

Selective Service System

P.O. Box 94739

Palatine, IL 60094-4739

MEN WHO ARE AGE 18 THROUGH 25 ARE

REQUIRED TO REGISTER

and can do so online at:

www.sss.gov

or they can complete this form.

HOW TO COMPLETE THIS FORM

• Read the Privacy Act Statement.

• Print your information in BLACK INK and CAPITAL LETTERS ONLY.

Block 1: Print your date of birth. Use a two-number designation for the month and

day and use a four-number designation for the year.

Block 2: Place an X in the correct box.

Block 3: Provide your Social Security Number if you have one since it is

mandatory to include this information. Leave this space blank if you do not yet

have a social security number.

Block 4: Print your full name as outlined on the card. Include any suffix (such as

Jr., or II), in the designated box, if applicable.

Block 5: Print your current mailing address as outlined on the card. Use the two-

letter State abbreviation and enter your ZIP Code.

Block 6: Print today’s date. Use a two-number designation for the month and day

and use a four-number designation for the year.

Block 7: Sign your name in the box.

• Selective Service will send you a Registration Acknowledgement in the mail.

• If you do not receive a Registration Acknowledgement within 90 days,

it is your responsibility to contact the Selective Service System at the

following Address:

Selective Service System

Registration Information Office

P.O. Box 94638

Palatine, IL 60094-4638

PRIVACY ACT STATEMENT

The Military Selective Service Act, Selective Service regulations, and the President’s Proclamation

on Registration require that you provide the indicated information, including your Social Security

Number if you have one. The principal purpose of the requested information is to establish or verify your

registration with the Selective Service System. This information may be furnished to other government

agencies for the stated purposes on a selective basis. See Systems of Records SSS-9

http://www.sss.gov/PDFs/Systems%20of%20Records%202011.pdf

DEPARTMENT OF JUSTICE - for review and processing of suspected violations of the Military

Selective Service Act, or for perjury, and for defense of a civil action arising from administrative

processing under such Act.

DEPARTMENT OF STATE & U.S. CITIZENSHIP AND IMMIGRATION SERVICES - for collection and

evaluation of data to determine a person’s eligibility for entry/reentry into the United States and for U.S.

citizenship.

DEPARTMENT OF DEFENSE & U.S. COAST GUARD - for exchange of data concerning registration,

classification, induction, and examination of registrants and for identification of prospects for recruiting.

DEPARTMENT OF LABOR - to assist veterans in need of data concerning reemployment rights, and for

determining eligibility for benefits under the Workforce Investment Act.

DEPARTMENT OF EDUCATION - to determine eligibility for student financial assistance.

OFFICE OF PERSONNEL MANAGEMENT & U.S. POSTAL SERVICE - to determine eligibility for

employment.

DEPARTMENT OF HEALTH AND HUMAN SERVICES - to determine a person’s proper Social Security

Number and for locating parents pursuant to the Child Support Enforcement Act.

STATE AND LOCAL GOVERNMENTS - to provide data which may constitute evidence and facilitate the

enforcement of state and local law.

BUREAU OF CENSUS - for the purposes of planning or carrying out a census or survey or related

activity pursuant to the provisions of Title 13.

ALTERNATIVE SERVICE EMPLOYERS - for exchange of information with employers regarding a

registrant who is a conscientious objector for the purpose of placement and supervision of performance

of alternative service in lieu of induction into military service.

GENERAL PUBLIC - Registrant’s name, Selective Service registration number, date of birth, and

classification. (Military Selective Service Act 50, U.S.C. App. 456h)

Failure to provide the required information may violate the Military Selective Service Act. Conviction for

such a violation may result in imprisonment for up to five years and/or a fine of not more than $250,000.