______________________________
_________________________________________________ _________________________________ _________
OMB Control No. 3095-0071
Expiration Date: 09–30–2021
SELECTIVE SERVICE SYSTEM RECORDS REQUEST
Year of Birth Prior to 1960
National Archives & Records Administration
Provide the following information and National Archives – Saint Louis
mail this form with any attachments to: P.O. Box 38757
Saint Louis, MO 63138-0757
DO NOT PROVIDE CREDIT CARD INFORMATION; IF RECORDS ARE FOUND, YOU WILL RECEIVE A REQUEST FOR PAYMENT
A. REGISTRANT INFORMATION (PLEASE PRINT)
Name: ___________________________ __________________________
Last First Middle
Selective Service Number (if known): ___________________
Date of Birth (MM/DD/YYYY): _____________
Home Address at Time of Registration: ______________________________________________________________
Street Address
City County State
Place of Registration (if known): ____________________________________________________________________
Street Address
_________________________________________________ _________________________________ _________
City County State
B. RECORD REQUESTED Registration Card
Please check one block Classification Ledger
Registration Card AND Classification Ledger
C. REQUEST PURPOSE
D. CONTACT INFORMATION (PLEASE PRINT)
Name: ________________________________________ Telephone Number: __________________
E-Mail Address: _________________________________ Street Address: _______________________________
City: __________________________________________ State: ___________ Zip Code: _____________
E. REQUESTER SIGNATURE
(Only if the Requester is the Registrant)
PRIVACY ACT AND PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENTS
Collection of this information is authorized by 44 U.S.C. 2104(a). Disclosure of this information is voluntary; however, we will
be unable to respond to your request if you do not furnish your name and address, and the minimum required information
regarding the record. The information is used by NARA employees to search for the record, to respond to you, to maintain
control over requests received and answered, and to facilitate preparation of internal statistical reports. You are not
required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Public burden reporting for this collection of information is estimated to be two
minutes per response. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to National Archives and Records Administration (MP), 8601 Adelphi Road,
College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA FORM 13172 (03-20)
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