MEN WHO ARE AGE 18 THROUGH 25 ARE
REQUIRED TO REGISTER
and can do so online at:
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 III), 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 your current electronic mailing address (email) as outlined on
Block 7: Print today’s date. Use a two-number designation for the month and
day and use a four-number designation for the year.
Block 8: Provide your current phone number.
Block 9: Sign your name in the box.
Mail the completed form to:
Selective Service System
Registration Information Ofﬁce
P.O. Box 94739
Palatine, IL 60094-4739
Selective Service will send you a Registration Acknowledgment in the mail.
If you do not receive a Registration Acknowledgment within 90 days, it is your
responsibility to contact the Selective Service at 847-688-6888.
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
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.
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
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. 3806(h))
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.