A. STUDENT INFORMATION
Last Name First Name M.I. Student ID Number (begins with 1 or 3)
Email Address Telephone Number Date of Birth
B. SELECTIVE SERVICE OPTIONS
Option 1: Registered with Selective Service (Indicate which document you are submitting to verify registration.).
Signed Selective Service Registration Card.
Confirmation of Registration printed from www.sss.gov
.
Option 2: Exempt from Selective Service (Choose ONE exempt status and indicate the accompanying documentation).
I am not yet 18 (___ Selective Service Status Letter ___ State ID ___U.S. Passport ___ Birth Certificate).
I was born before 1960 ( ___ Selective Service Status Letter ___ State ID ___U.S. Passport ___ Birth Certificate).
I am currently on active duty in the armed forces ( ___ DD Form 4 ___Active Duty Card ___ DD-214).
I entered the United States after the age of 26 ( ___ Foreign Passport with Date of Entry Stamp ___ I-94 Card).
I am a citizen of the Republic of Palau, the Republic of the Marshall Islands, or the Federated States of Micronesia
( ___ Passport from the applicable country of citizenship).
Option 3: Explanation for not registering with Selective Service (Select what best explains your circumstance and indicate that you
are also providing the supplemental documentation to accompany the explanation).
I served in the U.S. Armed Forces and didn’t realize I had to register.
I was hospitalized, incarcerated, or institutionalized between the ages of 18-26.
I did not know I was required to register with Selective Service.
I am also including ALL of the following documentation:
A Selective Service Status Letter.
A typed and signed statement explaining any extenuating circumstances and/or that the failure to register was not knowing
and willful, including a detailed timeline for the entire period 18 until 26 years old.
Any relevant documentation
(for example, a student who served in the armed forces between the ages of 18-22, but did not register after being
discharged thinking it not necessary for having served, would provide a DD-214 to show period of enrollment).
C. SIGN THIS WORKSHEET
By signing this worksheet, I (we) certify that all the information reported on this worksheet to qualify for federal student aid is
complete and correct. If you are dependent for financial aid purposes, at least one parent must sign. Warning: If you purposely give
false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
________________________________ __________ ______________________________ __________
Student’s signature Date Parent’s signature (dependent students only) Date
