16MSCSER 1/28/2016
Please complete the form below.
Student Name: ___________________________________________ HCC ID: ________________
Check one box that apply as to why you did not register with Selective Service.
I am a female - Not required to register. I am not age 18 or over; my birthdate is: ____________
I was required to register. I knowingly and willfully
refused to register.
I am a male born between 3/29/1957 and 12/31/1959
I was not
required to register.
I was in the military. (Please attach copy 4 of the
DD214)
I am a transsexual. (Attach copy of birth certificate)
I was INCARCERATED, INSTITUTIONALIZED,
HOSPITALIZED, OR CONFINED TO HOME:
List dates during which you were (circle appropriate
situation) incarcerated, institutionalized, hospitalized, or
confined to home. For multiple dates, list all.
________to ________, ________to________,
________to_________ ________to ________,
Attach proof of each instance
I was a NONCITIZEN/ALIEN: Date you entered the United
States for the first time: _______________
INS status at time of entry: ______________
List all alien status(es) held since entering the country.
_______to_______
USCIS Status: _______________
_______to_______
USCIS Status: _______________
Attach copies of supporting documentation
If none of these apply to you, attach a typed explanation as to why you did not register for Selective
Service from age 18 to 25. [Office use: Please scan the explanation with form.]
Attach any documentation to this form that is required
I understand that decisions regarding eligibility for student financial assistance are made by the Student
Financial Aid Office, not the Selective Service System.
I certify that all information submitted with this form is true and complete to the best of my knowledge.
Signature ______________________________________________ Date ____________________
According to Federal Law, a man between the ages of 18 and 24 must register with Selective Service regardless of
his citizenship status. If you failed to register with Selective Service you are not eligible to receive any federal
financial assistance (i.e. Federal Pell Grant, Federal Supplemental Education Opportunity Grant, Academic
Competitiveness Grant, Federal Work Study, Federal Stafford Loans, etc.)
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
finaid@hagerstowncc.edu
FAX: 301-791-9165
Selective Service Form
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
