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United States Secret Service (United States Secret Service)

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United States Secret Service
Supplemental Security Clearance Forms
(Rev. 08/2020)
Instructions
You are being considered for a position with the United States Secret Service. Since
all Secret Service employees are required to have a Top Secret Security Clearance,
the enclosed background investigation forms are being provided for your immediate
completion.
Once you have been asked by a Secret Service representative to complete this
package, please note the following instructions.
Save this packet as a .pdf document to your computer or an external drive
prior to completing any of the forms. Failure to do this, or saving the packet in
another format, could result in loss of your information.
All forms must be typed. If you have the paper-based version of this packet,
but you are able to complete this packet in electronic format, please call your
designated Secret Service point-of-contact so we can send you an Adobe
Acrobat-based version of this packet.
Ensure that ALL questions are answered or addressed. If a question does not
apply (and it is not a yes/no question), indicate N/A for not applicable.
Please sign the SSF 3230A Disclosure & Authorization Pertaining to
Consumer Reports Pursuant to the Fair Credit Reporting Act, do not sign or
initial any of the forms unless otherwise indicated. (Your signatures must be
witnessed by Secret Service representatives).
When the packet is completed, save all information in portable document format
(.pdf).
Prior to printing this packet, choose “File” > “Print,” and then click “Advanced.”
(The location of the Advanced button varies, depending on your version of Reader
or Acrobat.) Mac OS Users: If you don't see the Advanced button, click the Down
Arrow (to the right of the Printer pop-up menu).
Select “Print as Image.” This ensures proper printing of your information. The
location of the “Print as Image” options varies, depending on your version of Adobe
Reader or Acrobat. Click “OK” to close the “Advanced Print Setup” dialog box, and
then click “OK” to print. Mac OS Users: Click “Print” and then choose “Adobe
PDF” to ensure the documents are appropriately saved.
Completion of the SSF 3300 and SSF 3300A are only required for positions
requiring a physical examination. Please see your conditional offer of
employment letter/e-mail to see if your position requires a physical.
The SSF 4398 – Eye Examination may be submitted with the package if
time permits, or after the e-QIP is submitted if time does not permit. Do
not hold up the e-QIP submission for the SSF 4398 Eye Examination form.
All supplemental forms must be uploaded into e-QIP under “attachments.”
NAME OF CANDIDATE
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
ACKNOWLEDGMENT OF SECURITY
CLEARANCE REQUIREMENTS
THIS FORM MUST BE SIGNED BY ALL CANDIDATES WHO ARE TO BE APPOINTED ON A CONTINGENCY BASIS.
I understand that I am being considered for
appointment with the U.S. Secret Service
based on a contingent security investigation.
I understand that, if accepted, continued
employment with the U.S. Secret Service is
contingent on the satisfactory completion of a
special security background investigation and,
if the position is considered critical-sensitive,
the granting of a Top Secret clearance.
SIGNATURE OF CANDIDATE
DATE SIGNED
SIGNATURE OF WITNESS
DATE SIGNED
DISTRIBUTION: ORIGINAL - OFFICIAL PERSONNEL FILE CC - SECURITY CLEARANCE DIVISION CC - CANDIDATE
SSF 1871 (2/2003) Page 1 of 1
Declaration for Federal Employment*

 
  
Instructions
-
   
   
   
  

    
    
 
  X 
   
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Privacy Act Statement
       
         
       
         
  
     
          
        
    
   
      
    
       
  
 
      
    
    
     
       
     

        

     
    
     
 
 
Public Burden Statement

          
        
         
        
        
   
 
5 u S.C.  & 

  
   
  

  


     
  
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  
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  
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  
   
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  
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   
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

 •
 •
    

   

 
 

  
 
 
  

    
    
    







      
 
  
 
         
       


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 
       
 
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   
         
  
  
    
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 
      
 
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     
    
      
    
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 
 
      
     
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 



  
  

 
 
 
    
      

  
  
 
 

 
  
  
      

   
 
       
  
   
 
 
        
    
   
    
    

   
       







 
 









 

 



 
   



     
 

 
 
 

 




IF SUBMITTING ELECTRONICALLY, AN "/S/"
FOLLOWED BY YOUR TYPED NAME WILL SERVE
IN LIEU OF AN ACTUAL SIGNATURE.
A polygraph examination will be required during the application process. This polygraph examination will assist the Secret
Service in verifying the background information provided by the applicant on the SF 86, SSF 86A, and other areas of
significant security interest. Voluntary consent is required: however, refusal results in employment ineligibility. Refusal
will not be made part of personnel files, but will be considered as a withdrawal from the application process.
By executing this form, I acknowledge that I have been advised of the requirement of polygraph testing as a condition of
employment. I understand that any information I provide which evidences a potential violation of law may be provided to
the appropriate law enforcement authorities.
Further, I acknowledge that if I am currently employed by a law enforcement agency of a Federal, state, or local
jurisdiction or occupy any position, whether paid or unpaid, involving contact with children or involving the public safety or
trust, any information developed as a result of the polygraph examination may be made available to my employer and/or
referred to the appropriate authority at the discretion of the United States Secret Service.
Signature of Applicant
Date
Witness
Date
SSF 3213 (Rev. 5/2004)
Page 1 of 1
ADVISEMENT OF THE REQUIREMENT FOR POLYGRAPH EXAMINIATION FOR EMPLOYMENT
POLYGRAPH EXAMINATION
United States Secret Service
DEPARTMENT OF HOMELAND SECURITY
Catalog Number 68889B www.irs.gov
Form
14767 (Rev. 6-2020)
Form 14767
(June 2020)
Department of the Treasury - Internal Revenue Service
Consent to Disclose Tax Compliance Check
1. Taxpayer Information
First name Middle initial Last name Suffix Social Security Number (SSN)
Street address
City State ZIP code Online code (if applicable)
2. Appointee
Street address
City State ZIP code Contact telephone number
Authorization
I authorize the IRS to disclose a Tax Compliance Report containing confidential tax return information to the designated federal appointee above. The
Tax Compliance Report will disclose whether or not I am compliant with my United States federal tax obligations and provide applicable supporting
details from the tax account associated with my SSN limited to:
1. Individual income tax filing obligations
(Tax Form Number 1040), whether the return was filed timely or late (with regard to valid extensions), for the four
(4) most recent tax periods; and when there is no return on file and filing was required, for up to the six (6) most recent tax periods.
2. Business taxes for which I am personally liable. As a sole-proprietor I may be liable for filing employment and/or excise tax returns for my
business (See instructions). If applicable, the report will identify the type of unfiled business tax return(s) and tax period(s), if a return is required
based on my business’ reporting requirements.
3. Unpaid assessed tax liabilities (i.e. tax debts) for any tax period for which the collection statute of limitations has not expired. (This is generally (10)
years from the date of assessment unless extended).
If all taxes are paid the report will state that no taxes are due. For unpaid taxes as of the date of
the report, the tax period; the amount owed (total balance due including tax, penalties and interest); primary reason for the assessment; the existence of
a tax lien, if applicable, and the current status of the account (e.g. installment agreement, appeal or claim pending, etc.) will be listed.
4. Whether federal taxes were paid late for the four (4) most recent tax years. If applicable, the report will identify the type of tax and tax period(s)
with payments made after the due date of the return.
5. Whether a fraudulent failure to file or civil tax fraud penalty was assessed in the last five (5) years. If applicable, the report will identify the tax
period, date, and amount of the penalty(ies) assessed, even if fully paid by the date of the report.
The IRS will not release copies of my tax return, a transcript of my account nor information concerning my income, dependents or filing status, to the
appointee pursuant to this authorization.
I certify that I have the authority to execute this consent. Under penalties of perjury, I declare that I have authority to execute this consent and the
information provided is to the best of my knowledge and belief, true, correct, and complete.
Signature of Taxpayer (The signature and date must be handwritten and the consent must be received by the IRS within 120-days of the date it was signed.)
Signature Date
Taxpayer Notification
Internal Revenue Code, Section 6103(c), limits disclosure and use of return information provided pursuant to your consent and holds the recipient
subject to penalties, brought by private right of action, for any unauthorized access, other use, or redisclosure without your express permission or
request.
Designated Appointee Official Notification
Internal Revenue Code, Section 6103(c), limits disclosure and use of return information received pursuant to the taxpayer’s consent and holds the
recipient subject to penalties for any unauthorized access, other use, or redisclosure without the taxpayer’s express permission or request.
Federal agency name Assigned agency code
FD407
245 MURRAY LANE, SW, BLDG. T-5
WASHINGTON
DC
20223
(202)406-6658
Page 2
Catalog Number 68889B www.irs.gov
Form
14767 (Rev. 6-2020)
Instructions for Form 14767, Consent to Disclose Tax Compliance Check
Purpose of Form
The purpose of the tax compliance report is to provide the appointee
federal tax information necessary for use in conducting a background
investigation or determining one or more of the following:
• Suitability for government employment or appointment,
• Eligibility for access to federally controlled facilities and information
systems,
• Authorization to be issued a federal credential or receive sensitive
government information,
• Access to classified information,
• Contractor or federal employee fitness,
• Monitoring tax compliance, if required as a condition of employment, or
• Other purposes authorized by Federal law
The purpose of this form is to authorize the Internal Revenue Service
(IRS) to prepare a tax compliance report that discloses confidential tax
information to a third-party appointee. The appointee is the federal
agency identified on the form which may be your current or prospective
employing or contracting agency or a federal investigative service
provider agency for example, the Defense Counterintelligence and
Security Agency (DCSA) which conducts background investigations for
Federal agencies. This form may also be used to request a tax
compliance report for other authorized uses. Without a valid consent, the
IRS is prohibited by law from disclosing any of this information to third
parties. Pursuant to this consent, only your tax compliance report and
limited details from your tax account will be disclosed.
Authorized Disclosures
If you timely filed and paid your taxes, the report will state that you are
compliant with your tax obligations. The report will only address facts of
filing and your compliance status on all authorized tax periods. If you
have a delinquent Federal tax liability (i.e. unpaid tax debt), we will only
disclose limited information sufficient to explain the specific delinquency.
If there are overdue filings or payments the report will state that you are
non-compliant or identify the compliance issue if there are extenuating
circumstances (e.g. litigation, combat zone, installment agreement) and provide
an explanation along with the current status of your account. For
example, if you owe taxes for 2018 and are repaying through an
approved installment agreement, we will report the amount owed and the
fact that you have a current installment agreement.
We will report an assessment of a civil tax fraud penalty or fraudulent
failure to file penalties whether paid or unpaid. These penalties relate to
the non-filing or non-payment of income, excise and employment tax
returns (for example the trust fund recovery penalty; frivolous filing penalty; willful
failure to pay, evade or defeat the stamp tax; sanctions awarded by the Tax Court).
Generally, these penalties are assessed in addition to any income tax
liability under your Social Security Number (SSN).
Your authorized appointee will use your tax records for purposes allowed
by federal law which may include redisclosure to others during the
maintenance and processing of your suitability or eligibility determination.
Contact your appointee to obtain additional information about routine
uses of your tax compliance report.
Business Information
Do you own a business? If you own a business as a sole proprietor, we
will research and report any delinquent excise or employment tax
liabilities associated with your business. You would report the income
and expenses of your business on Schedules C or F attached to your
individual income tax return. This only applies if you have employees or
are subject to excise taxes for which you are personally responsible for
paying even though these taxes are assessed using the business’s
Employer Identification Number (EIN). The employment or excise tax
returns are not reported on your individual income tax return but are filed
separately with the IRS (for example, Form 940, 941,720). If you do not have
employees or are not required to pay these taxes, you would not file any
of these business returns.
Taxpayer Information
Enter your name, Social Security Number (SSN) and address in the
spaces provided. If you used the IRS online tax check service, enter the
Online Code you received when you were unable to verify your identity.
Leave the Online Code blank if you did not use the IRS online tax check
service.
Authorized Appointee
The Federal agency that will receive your confidential tax information
should have provided the information for this section. They will identify
the name of the agency, assigned agency code, the agency’s mailing
address and contact telephone number. If they did not provide this
information, ask them to add it before you sign. Do not sign this consent
if this information is blank.
Signature of Taxpayer
You must sign and date the consent in order for the IRS to disclose your
tax information to the Federal agency appointee named on the consent.
The signature and date must be handwritten. When signing the
document, you are authorizing the release of specific tax information
from IRS records.
Privacy Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. This form authorizes the IRS to disclose your confidential tax information to
the federal agency you appoint. This form is provided for your convenience and its use is voluntary. The information is used by the IRS to determine what confidential tax
information your appointee can receive. Internal Revenue Code section 6103(c) and its regulations require you to provide this information if you want to designate an
appointee to inspect and/or receive your confidential tax information. Under section 6109, you must disclose your identification number. If you do not provide all the
information requested on this form, we may not be able to honor the authorization. Providing false or fraudulent information may subject you to penalties.
Routine uses of this information include disclosure to the Department of Justice for civil or criminal litigation and to other federal agencies, as provided by law. We may
disclose this information to cities, states, the District of Columbia, and U.S. commonwealths and possessions to administer their laws. We may also disclose this information to
other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat
terrorism. We may disclose this information to persons for purposes of collecting debts through salary and administrative offsets and to the news media as described in IRS
Policy Statement 11-94. We may also disclose this information to appropriate persons to assist in responding to compromises of information.
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
DISCLOSURE AND AUTHORIZATION
PERTAINING TO CONSUMER REPORTS
PURSUANT TO THE FAIR CREDIT REPORTING ACT
This is a release for the United States Secret Service (or other component of the Department of
Homeland Security) to obtain one or more consumer credit reports about you in connection with
your employment (or application for employment) with the Department of Homeland Security or
one of its components, including as a contract employee. One or more consumer credit reports
about you may be obtained for employment purposes, including evaluating your fitness for
employment, promotion, reassignment, retention or access to classified information.
I, ,
hereby authorize the United States Secret Service (or other component of the
Department of Homeland Security) to obtain such report(s) from any consumer
credit reporting agency for employment purposes. Copies of this authorization
that show my signature are as valid as the original signed by me.
Signature
Date
Social Security Number
Additional information regarding the credit bureaus that report credit history can be obtained via their home pages at:
www.experian.com
www.transunion.com
www.equifax.com
Please retain this information to assist you with any credit issues.
PRIVACY ACT STATEMENT: YOUR SOCIAL SECURITY NUMBER (SSN) IS SOLICITED UNDER THE AUTHORITY OF EXECUTIVE ORDER 9397. THIS INFORMATION WILL BE USED
TO IDENTIFY AND SEPARATE INDIVIDUALS WITH SIMILAR OR IDENTICAL NAMES OR INITIALS. DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER AND OTHER REQUESTED
INFORMATION IS VOLUNTARY; HOWEVER, FAILURE TO P ROVIDE YOUR SSN AND OTHER INFORMATION REQUE STED MAY PROHIBIT PROCESSING AND CAUSE DENIAL OF
ACCESS TO SECURE AREAS OR SENSITIVE MATERIAL PROTECTED BY THE UNITED STATES SECRET SERVICE.
SSF 3230A (11/2003) Page 1 of 1
PRE-QUESTIONNAIRE:
The Office of Personnel Management (OPM) defines foreign contacts and associations as any foreign relatives, friends,
business or professional associates, and/or person who is a citizen of a foreign country, even if they are a resident of the U.S.
Of particular concern are foreign contacts and associations that create a heightened risk of foreign exploitation, inducement,
manipulation, or pressure from Foreign Intelligence and Security Services, such as "sexual relations with foreign nationals -
especially adulterous affairs or use of prostitutes."
More specifically, foreign contacts are defined as interaction not related to one's official duties with any foreign entity or foreign
national that is social, business, romantic, intimate, or sexual in nature. Reportable contact includes in-person, written
correspondence, telephonic communications, or electronic communication through any means including, but not limited to,
Blackberry devices, iPods, video camera, webcams, etc.; and via any method, including but not limited to, the Internet, e-mail,
chat rooms, Facebook and other social networking sites, gaming sites, etc.
Relatives are defined as spouse, cohabitants, and both you and your spouse's parents, step-parents, foster parents, brothers
and sisters (to include halves, steps, and in-laws), children (to include foster, step, adopted), aunts (all sisters of
parents/spouses of uncles), uncles (all brothers of parents/spouses of aunts), cousins (all children of aunts and uncles).
Check all that apply:
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
CITIZENSHIP OF RELATIVES AND ASSOCIATES
DateSignature of Applicant or Employee
SSF 4336 (08/2013)
Page 1 of 4
Do you have any associates/friends/acquaintances that were born outside of the United States?
Does your spouse/cohabitant have any relatives that live or work outside of the United States?
If you checked any of the above, please complete the attached form addressing each section for all applicable
individuals.
Does your spouse/cohabitant have any associates/friends/acquaintances that were born outside of
the United States?
Do you have any relatives that live or work outside of the United States?
Do you have any relatives that were born outside of the United States?
Do you have any associates/friends/acquaintances that live or work outside of the United States?
Does your spouse/cohabitant have any relatives that were born outside of the United States?
Does your spouse/cohabitant have any have any associates/friends/acquaintances that live or work outside of the
United States?
Not applicable
INSTRUCTIONS: Complete this form as it applies to you and your family and also as it applies to your spouse/cohabitant AND HIS/HER
FAMILY if the relative or associate:
Lived or currently lives in a foreign country
Worked or currently works for a foreign government
Was born outside of the U.S., regardless of current citizenship
Is a non-US citizen residing the U.S.
Has had contact with you in the last seven years.
Relatives and extended family members are defined as spouse, parents (to include stepparents), brothers, sisters, stepbrothers,
stepsisters, half brothers, half sisters, children, aunts, uncles, and cousins.
For associates, list only those with whom you have a close and/or continuous relationship.
For item 5, "Citizenship code number," use the codes below to identify proof of citizenship status:
.
.
.
.
17. Additional information/explanation:
2. Full name (last, first, middle):1. Relative or associate type (e.g., spouse, cousin, friend, etc.):
5. Citizenship code number:
3. Gender:
Male
Female
6. Current address:
7. Complete date and place of birth: 8. Social Security Number:
9. Name and address of employer:
10. Degree of contact/method:
12. Current citizenship:
14. Naturalization certificate number:13. Date and place of U.S. naturalization:
15. Date and place of entry into the U.S.:
16. Alien registration number:
1. Naturalized citizen of the U. S. 6. Non Immigrant
2. Permanent resident of the U. S. 7. Deported
3. Fiancé / Fiancée VISA 8. Not legally residing in the U. S.
4. Work VISA 9. Other (explain)
5. Student VISA
For item 10, "Degree of contact and method," indicate how you have contact with this individual (e.g. telephone, text messaging, e-mail,
in-person, social networking, webcams, written correspondence, etc.)
For item 13, "Date and place of U.S. naturalization," if the relative or associate is a naturalized citizen of the U.S., provide the date
naturalization was issued and the location where the person was naturalized (court, city, State and certificate number).
If the relative or associate was born on a U.S. Military installation, please indicate this in item 17, "Additional information/explanation."
Please complete ALL requested information.
I. FIRST FOREIGN RELATIVE OR ASSOCIATE:
SSF 4336 (08/2013)
Page 2 of 4
4. Maiden name and/or other names used:
.
11. Date of last contact:
II. SECOND FOREIGN RELATIVE OR ASSOCIATE:
III. THIRD FOREIGN RELATIVE OR ASSOCIATE:
SSF 4336 (08/2013)
Page 3 of 4
17. Additional information/explanation:
2. Full name (last, first, middle):1. Relative or associate type (e.g., spouse, cousin, friend, etc.):
5. Citizenship code number:
3. Gender:
Male
Female
6. Current address:
7. Complete date and place of birth: 8. Social Security Number:
9. Name and address of employer:
10. Degree of contact/method:
12. Current citizenship:
14. Naturalization certificate number:13. Date and place of U.S. naturalization:
15. Date and place of entry into the U.S.:
16. Alien registration number:
4. Maiden name and/or other names used:
11. Date of last contact:
17. Additional information/explanation:
2. Full name (last, first, middle):1. Relative or associate type (e.g., spouse, cousin, friend, etc.):
5. Citizenship code number:
3. Gender:
Male
Female
6. Current address:
7. Complete date and place of birth: 8. Social Security Number:
9. Name and address of employer:
10. Degree of contact/method:
12. Current citizenship:
14. Naturalization certificate number:13. Date and place of U.S. naturalization:
15. Date and place of entry into the U.S.:
16. Alien registration number:
4. Maiden name and/or other names used:
11. Date of last contact:
SSF 4336 (08/2013)
Page 4 of 4
IV. FOURTH FOREIGN RELATIVE OR ASSOCIATE:
V. FIFTH FOREIGN RELATIVE OR ASSOCIATE:
17. Additional information/explanation:
2. Full name (last, first, middle):1. Relative or associate type (e.g., spouse, cousin, friend, etc.):
5. Citizenship code number:
3. Gender:
Male
Female
6. Current address:
7. Complete date and place of birth: 8. Social Security Number:
9. Name and address of employer:
10. Degree of contact/method:
12. Current citizenship:
14. Naturalization certificate number:13. Date and place of U.S. naturalization:
15. Date and place of entry into the U.S.:
16. Alien registration number:
4. Maiden name and/or other names used:
11. Date of last contact:
17. Additional information/explanation:
2. Full name (last, first, middle):1. Relative or associate type (e.g., spouse, cousin, friend, etc.):
5. Citizenship code number:
3. Gender:
Male
Female
6. Current address:
7. Complete date and place of birth: 8. Social Security Number:
9. Name and address of employer:
10. Degree of contact/method:
12. Current citizenship:
14. Naturalization certificate number:13. Date and place of U.S. naturalization:
15. Date and place of entry into the U.S.:
16. Alien registration number:
4. Maiden name and/or other names used:
11. Date of last contact:
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
GINA DISCLAIMER
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits
employers and other entities covered by GINA Title II from requesting or
requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this
law, we are asking that you not provide any genetic information when
responding to this request for medical information. "Genetic information"
as defined by GINA, includes an individual's family medical history, the
results of an individual's or family member's genetic tests, the fact that an
individual or an individual's family member sought or received genetic
services, and genetic information of a fetus carried by an individual or an
individual's family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.
SSF 4313 (01/2011)
Page 1 of 1
II. Physical Fitness History
I. General History
United States Secret Service
MEDICAL HISTORY QUESTIONNAIRE
1c. Date of Birth1a. Date 1b. Social Security No.*1. Employees Full Name (Last, First, Middle Initial)
1. Marital Status (check appropriate box)
Number of children
Widowed
Ages of children
MarriedSingle
4. How Long in Current Occupation/Position?3. Employee's Occupation/Position 5. Highest Level of Education (circle one)
Have you ever been a regular smoker? Yes
Please check if you regularly smoke - cigarettes number of times per daypipe cigars
7. Please check if you drink
How long have you been smoking?
BeerLiquor Wine
8. Do you drink caffeinated beverages (i.e. coffee, cola, tea)?
NoYes
9. Please respond to the following series of questions using the code:
1. Never or Very Infrequently
How often do you feel tense, anxious, and/or have nervous indigestion?
2. Occasionally
3. Frequently
Do you have headaches and/or pain/tension in the neck and/or shoulders?
Do you get 7-8 hours of sleep per night?
2.
6.
7a. Amount per day or week (please specify)
8a. Amount per day or week (please specify)
No / If you have quit......when?
Do you take time to relax and do things you enjoy?
Do you take tranquilizers (or other drugs) to relax?
Do you eat, drink, and/or smoke in response to stress/tension?
E. Environment (locations) -
2. Are you presently active in the U.S. Secret Service Fitness Program?
1. How physically fit do you feel at present? (check appropriate box)
Very Fit NoAverage Above AverageUnfit YesBelow Average
3. Aerobic Exercise (Cardiovascular Endurance Component) is accomplished through which of the following activities?
A. Mode - 5. Other1. Walking 2. Jog/Run 3. Swimming 4. Biking
Regarding the above listed activities --
1. Two or less 2. Three 3. Four 4. Five or more
2. 15-301. Less than 15 4. 60 or more3. 30-60C. Duration (minutes per workout) -
3. Somewhat hard1. Very, very light 2. Very lightD. Intensity (your perceived exertion most consistently is) -
4. Hard 5. Very hard 6. Very, very hard
1. At home 2. At work 3. OtherE. Environment (exercise is accomplished at the following locations) -
4. Strength Development Dynamic Strength Component) is accomplished through which of the following activities?
1. Calisthenics 3. Universal 4. Nautilus2. Free-weight training (barbell/dumbell)A. Mode -
5. Other
1. Two or less 2. Three 3. Four 4. Five or moreB. Frequency (days per week) -
4. 60 or more1. Less than 15 2. 15-30 3. 30-60C. Duration (minutes per workout) -
D. Intensity - 1. Heavy weight/low repetitions 2. Light weight/high repetitions 3. Combination of 1 and 2
2. At work1. At home 3. Other (Name/location of club, etc.)
B. Frequency (days per week) -
5. I stretch after exercising (flexibility component) -
1. Almost never 2. Occasionally 3. Frequently 4. Very Frequently 5. Almost always
6. I approach exercise in a relaxed manner -
1. Almost never 5. Almost always
2. Occasionally 3. Frequently 4. Very Frequently
7. I avoid the extremes of too much or too little exercise -
1. Strongly agree 4. Disagree 5. Strongly disagree3. Neutral/not sure2. Agree
8. I supplement program exercise with the following activities - (list individual/team sport activities and/or leisure time activities)
12 13 14 15 16 16+
''Exception to Standard From 93 approved by GSA/IRMS 9/90'', as outlined in 41 CFR 201-45.
SSF 3300A (Rev. 4/10)
Page 1 of 5
DEPARTMENT OF HOMELAND SECURITY
Controlled with medication?
If yes, name.
Other known allergies?
If yes, list and describe symptoms.
Are you allergic to any medications?
If yes, list and describe reactions.
III. Past Medical History
1. Check each item "Yes" or "No". Every item checked "Yes" must be fully explained in blank space on right.
A. Have you been refused employment or been unable
to hold a job or stay in school because of:
1. Sensitivity to chemicals, dust, sunlight, etc.
Yes No
Yes No
2. Inability to perform certain motions.
Yes
3. Inability to assume certain positions.
No
Yes No
4. Other medical reasons (If yes, give reasons.)
B. Have you ever been treated for a mental condition?
(If yes, specify when, where, and give details).
Yes No
C. Have you ever been denied life insurance?
(If yes, state reason and give details).
Yes No
D. Have you had, or have you been advised to have,
any operation? (if yes, describe and give age at
which occurred.)
Yes No
Yes No
.
Yes No
Yes No
Yes No
Yes No
J. Have you ever received, is there pending, or have
you applied for pension or compensation for
existing disability? (if yes, specify what kind,
granted by whom, and what amount, when, why.)
Yes No
K. Are you presently under any medication? (Please
include non-prescription.)
Yes No
2. Diagnostic Tests 3. Allergies -
Yes No Date
Chest X-Ray
NoYes
Kidney X-Ray
Stomach X-Ray (Upper GI)
NoYes
Tuberculosis Skin Test
Have you ever had a positive Tuberculosis Skin Test?
4. Immunizations
NoYes
Yes No
Smallpox
Typhoid
Polio
Tetanus date
Measles
Mumps
Have you ever had a blood transfusion?
E. Have you ever been a patient in any type of
hospital? (If yes, specify when, where, why, name
of doctor and complete address of hospital.)
F. Have you ever had any illness or injury other than
those already noted? (If yes, specify when, where,
and give details.)
G. Have you consulted or been treated by clinics,
physicians, healers, or other practitioners within the
past years for other than minor illnesses? (If yes,
give complete address of doctor, hospital, clinic,
and details.)
H. Have you ever been rejected for military service
because of physical, mental, or other reasons? (If
yes, give date and reason for rejection.)
I. Have you ever been discharged from military
service because of physical, mental, or other
reasons? (If yes, give date, reason, and type of
discharge: whether honorable, other than
honorable, for unfitness or unsuitability.)
Colon X-Ray (Lower GI, Barium Enema)
Gallbladder X-Ray
Electrocardiogram (EKG)
Graded Stress (EKG)
SSF 3300A (Rev. 4/10)
Page 2 of 5
IV. Review of Systems
NOTES: Describe each abnormality in detail. Enter pertinent item number before each comment.
YESNO
Have you had or do you have any of the following:
H-01 NOSE, MOUTH, THROAT
.01 frequent or severe nosebleeds
.02 persistent hoarseness
.03 nose or mouth problems
.04 sinus trouble
.05 persistent sore throat
H-02 EARS and HEARING
.01 hearing problems or loss of hearing
.02 other ear problems
.03 ringing or buzzing in your ears
.04 earaches or discharge from your ears
.05 dizziness
.06 exposure to prolonged loud noise
.07 wear a hearing aid
H-03 EYES AND VISION
.01 pain in your eyes or increased pressure
.02 blurry vision
.03 change in vision
.04 wear glasses or contacts
.05 eye trouble or visual problems
.06 glaucoma
.07 have you had radial keratotomy
.08 have you had any surgery on your eyes
H-04 HEART and CARDIOVASCULAR
.01 pain or tightness in the front or back of your chest during exertion
.02 pain or tightness in the front or back of your chest during anxiety
.03 swelling of feet or ankles
.04 cramps in the back of your lower legs when you walk
.05 extra, skipped or irregular heartbeats/pulse
.06 rapid heartbeats or palpitations
.07 circulatory problems
.08 known disease of arteries
.09 heart murmur
.10 elevated cholesterol/value:
.11 high triglycerides or blood fats/value:
.12 scarlet fever
.13 pericarditis
.14 heart trouble/disease/attack/coronary 0-1yr, 1-2 yrs, 2-5 yrs, over 5 yrs
H-05 PERIPHERAL VASCULAR SYSTEM
.02 high blood pressure
.03 varicose veins
.04 phlebitis
H-06 RESPIRATORY SYSTEM
.01 frequent chest colds
.02 wheezing or whistling in your chest
.03 chronic or bothersome persistent cough
.04 difficulty breathing
.05 daily cough or raising phlegm: persistent 3 months or longer
.06 shortness of breath with exertion, while sitting still, when lying down
.07 tuberculosis
.08 asthma
.09 bronchitis
.10 pulmonary emoblus (blood clot in lung)
.11 pneumonia
.12 emphysema
.13 allergies: hayfever, skin, other (refer to Section IV, No. 8)
H-07 ENDOCRINE and METABOLIC SYSTEM
.01 obesity or overweight/underweight
.02 diabetes
.03 high or low blood sugar
.04 thyroid gland problem
.05 pituitary gland problem
H-08 HEMATOPIETIC and LYMPHATIC SYSTEMS
.01 abnormal bleeding or clotting
.02 cough up blood
.03 blood disorder
.04 anemia
H-09 MUSCULOSKELETAL SYSTEM
.01 chronic lower back pain or problem
.02 pain in your legs or feet
.03 hot, swollen, stiff, or painful joints (which joints:)
.04 persistent ankle swelling
.05 trouble walking or using your hip, shoulder or knee joints
.06 muscle weakness
.07 cramps or weakness in your legs while walking
.08 movement impairment
.09 loss of extremity or digit
.01 cold feet and/or hands when others are comfortable in the same
room
SSF 3300A (Rev. 4/10)
Page 3 of 5
Review of Systems (continued)
NOTES: Describe each abnormality in detail. Enter pertinent item number before each comment.
YESNO
H-09 MUSCULOSKELETAL SYSTEM (continued)
.10 arthritis or rheumatoid arthritis
.11 gout
.12 high uric acid (value):
H-10 SKIN and COLLAGEN
.01 noticed " change in the color of your skin
.02 skin rashes or itching
.03 unusually dry skin
.04 growth on your skin that bothers you
.05 sores or wounds that do not heal
.06 change in color or size of warts or moles
.07 skin diseases or eczema
H-11 GENITOURINARY and REPRODUCTIVE SYSTEM
.01 burning or pain when you urinate
.02 urinate frequently
.03 difficulty starting/stopping your urinary stream
.04 urine loss when you cough or sneeze
.05 noticed blood when passing urine
.06 urinary tract problems
.07 prostrate problems
.08 nephritis
.10 had an operation to prevent pregnancy
.11 sexually transmitted disease
H-12 NEUROLOGICAL
.01 frequent and/or severe headaches
.02 localized weakness, numbness, or tingling in your head or
extremities/arms or legs
.03 feel unsteady on your feet or more clumsy
.04 double or blurred vision
.05 dizziness
.06 fainting
.07 epilepsy (seizures or convulsions)
.08 paralysis
.09 stroke
.10 any tremors or shakiness
.11 polio
H-13 GASTROINTESTINAL SYSTEM
.01 recent changes in your eating habits
.02 poor appetite
.03 stomach disorders such as heartburn indigestion, pain, ulcers, vomiting
blood, gas, fatty food intolerance
.04 nausea
.05 constipation, diarrhea, blood in stool, hemorrhoids, or colitis/
bowel trouble, or rectal polyps
.06 liver or gall bladder trouble
.07 cirrhosis of liver
.08 hepatitis
.09 hernia
H-14 GENERAL
.01 recently been drinking more water and/or fluids
.02 previous or recent unusual weight gain or loss
.03 usually feel tired
.04 worry a lot about your health
.05 any kind of cancer, tumor, growth, or cyst
.06 drug allergies (which drugs, reactions)
.07 do you have any other medical problems not previously mentioned?
Explain
.08 ever had exposure to AIDS virus
.09 presently on any medication
H-15 PSYCHIATRIC CONDITIONS
.01 trouble sleeping (how many hrs a night do you sleep)
.02 fatigue easily (cause if known)
.03 frequently or chronically depressed or anxious
.04 hospitalized for a nervous disorder
.05 psychiatric or psychologic consultation
.06 depression
.07 nervous trouble
H-16 WOMEN ONLY
.01 severe menstrual pain
.02 irregular menstrual periods
.03 extremely heavy flow
.04 vaginal discharge or itching
.05 had or have lumps in your breasts
.06 give yourself periodic breast exams
.07 know how to perform such a test
.08 are you now pregnant
last menstrual period
last pap smear
.09 any kidney problems such as stones, blood in urine, burning,
infection, etc.
SSF 3300A (Rev. 4/10)
Page 4 of 5
V. Review of Systems Continuation Sheet
Comment on any items checked YES - Enter pertinent number beside each comment:
Physicians Comments:
I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics
mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service.
Typed or Printed Name of Examinee Signature
PRIVACY ACT STATEMENT: Executive Order 9397 allows Federal agencies to use the Social Security Number of an individual to avoid confusion caused by employees with the
same or similar names. However, failure to provide the information requested may delay processing under Secret Service Mandatory Medical Examination Program.
SSF 3300A (Rev. 4/10)
Page 5 of 5
SSF 4398 (Rev. 02/2018) Page 1 of 1
DEPARTMENT OF HOMELAND SECURITY
United States Secret Servic
e
EYE EXAMINATION REPORT
DIRECTIONS:ThisEyeExaminationReportmustbecompletedattheapplicant’sownexpenseandMUSTbesubmittedtocontinueintheappli c ationprocess.Items1‐
2mustbecompletedbyapplicant,and3‐7mustbecompletedbyapplicant’sEyeCareProvider(i.e.Optom e trist,Ophthalmologist)basedonCURRENTeye
examination.
1A.NAME
(Last,First,Middle)
1B.DOB
(MM/DD/YYYY)
1C.SEX
(MorF)
1D.TELEPHONENo.
2A.HOMEADDRESS
(No.Street,City,State,ZipCode)
2B.RECRUITINGOFFICE
2C.POSITIONAPPLYINGFOR(i.e.SA,UD,Other)
3. VISUALACUITY(
UseSnellenEquivalents)
WITHOUT
CORRECTION
WITHCORRECTION
CHECKIFAPPLICABLE:
CONTACTLENSES SPECTACLELENSES
DISTANTVISION
O.D.
O.S.
O.U.
NOTE–Ifcontactlensesareused,correctednearvisualacuityshouldbedeterminedwhiletheselensesareworn.
Stateifbifocalormonovisioncontactlens(es)areused.
4. PRESENTPRESCRIPTION
(Sphere,cylinder,axis)
A. CONTACTLENSES B. SPECTACLELENSES
O.D. O.S. O.D. O.S.
5. DESCRIBETYPEOFCONTACTLENSESUSED
6. VISIONCORRECTIONSURGERIES
–Listallprocedureswithdates.
7A.NAME,ADDRESS,&TELEPHONENo.OFEYESPECIALIST 17B.SIGNATUREOFEYESPECIALIST
DATEOFEYEEXAMINATION: __
MM/DD/YYYY
U.S. Secret Service
APPLICANT DRUG TESTING NOTIFICATION
Applicant's Name:
Notice
Applicants to all positions in the U.S. Secret Service will be required to submit to drug testing by urinalysis as a
precondition of employment. Any applicant who tests positive for the use of illicit drugs will be given no further
consideration for a position in this agency.
In those cases where the applicant is currently employed by a law enforcement or intelligence agency of a Federal, State,
or local jurisdiction, and the applicant tests positive for the presence of illicit drugs, the test results may be made available
to the head of that organization.
I certify that I have read the above statement and understand it fully.
Date Signature of Applicant
Signature of Witness (USSS)
Office of Witness
SSF 3309 (9/2009)
Page 1 of 1
DEPARTMENT OF HOMELAND SECURITY
DO NOT ATTEMPT TO COMPLETE THIS FORM UNTIL YOU HAVE READ THE FOLLOWING INSTRUCTIONS
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
DRUG HISTORY QUESTIONNAIRE
INSTRUCTIONS TO THE APPLICANT:
1. As an applicant with a conditional offer of employment from the United States Secret Service (USSS), any prior drug use, attempted
drug use, and/or experimentation must be disclosed before you can be considered for further processing. Disclosure of the purchase,
sale, distribution, or cultivation of drugs also must be disclosed. Do not include instances in which substances (except marijuana) were
prescribed, administered, or dispensed by a duly licensed physician for treatment of a legitimate medical condition.
2. Answer all questions completely or check (x) the box which applies. Note: We cannot accept your form if it is not complete.
4. If submitting electronically, an "/S/" followed by your typed name will serve in place of an actual signature.
3. Your initials are required at the bottom of each page.
SSF 4099 (Rev. 04/21/2017) Page 1 of 4
Enter your initials before going to the next page
5. YOU ARE INFORMED THAT THE ACCURACY OF ANY STATEMENT MADE IN THIS APPLICATION WILL BE INVESTIGATED
AND ARE SUBJECT TO A POLYGRAPH.
The USSS is committed to a drug-free workplace. Therefore, the unlawful use of drugs by USSS employees is not tolerated. Furthermore,
applicants for employment with the USSS who currently use illegal drugs will be found unsuitable for employment. The USSS does not
condone any prior unlawful drug use by applicants, but it is recognized that some otherwise qualified applicants may have used drugs at
some point in their past. The following policy balances the needs of the USSS to maintain a drug-free workplace and to accomplish its
protective and investigative missions by setting forth the criteria for determining whether prior drug use makes an applicant unsuitable for
employment. When adjudicating an applicant for a security clearance, drug usage is a critical factor but it is only one factor considered
when adjudicating the whole person.
APPLICANT DRUG POLICY STATEMENT
Marijuana includes but is not limited to cannabis, hashish, hash oil, medical cannabis, and tetrahydrocannabinol (THC) in both synthetic and natural forms.
Use of marijuana includes use or purchase for medicinal purposes or use or purchase in states or countries where use is legal. Personal use includes use
with friends, relatives, and family. Recreational use is defined as the sale, cultivation, or distribution, other than for personal use, not
intended for income or
profit.
Have you used or purchased marijuana?
Yes
No
An applicant for employment with the USSS shall not deliberately misrepresent his/her history of drug activity in connection with the
application for USSS employment. If deliberate misrepresentation is found, the applicant will be ineligible for employment. (Applicants will
sign a statement at the Factor V, Security Interview locking in their response. Any changes after signing this statement may result in the
applicant being ineligible for employment with the USSS for 3 years).
MISREPRESENTATION OF DRUG ACTIVITY
PROVIDE THE REQUESTED INFORMATION FOR ANY OF THE DRUGS YOU HAVE USED.
Marijuana
If yes, provide: Your age when last used or purchased:
The date when last used or purchased:
Have you sold, cultivated, or distributed marijuana for recreational use?
Yes
No
If yes, provide: the date you last sold, cultivated or distributed marijuana for recreational use:
Have you sold, cultivated, or distributed marijuana for income or profit?
Yes
No
MM
YYYY
MM
YYYY
Drug History Questionnaire - Continuation
Enter your initials before going to the next page
SSF 4099 (Rev. 04/21/2017) Page 2 of 4
Steroids include but are not limited to forms of anabolic steroids and corticosteroids, but do not include corticosteroids taken with a prescription.
Have you used or purchased steroids?
Yes
No
Steroids
If yes, provide: The date when last used or purchased:
Have you sold, distributed, or manufactured steroids?
Yes
No
Inhalants are volatile substances that produce chemical vapors that can be inhaled to induce a psychoactive, or mind-altering, effect. These include but are
not limited to solvents (paint thinners and removers, dry-cleaning fluids, degreasers, gasoline, glues, correction fluids, felt-tip markers); aerosols (spray
paints, deodorant and hair sprays, vegetable oil sprays for cooking, and fabric protector sprays); gases (medical anesthetics such as ether, chloroform,
halothane, nitrous oxide, butane, propane, and refrigerants); and nitrites (cyclohexyl nitrite, isoamyl (amyl) nitrite, and isobutyl (butyl) nitrite commonly known
as "poppers" or "snappers.")
Have you misused inhalants?
No
Inhalants
If yes, provide: The date when last used:Yes
Prescription drugs include, but are not limited to, Codeine, Oxycodone/Oxycontin, Morphine, Ritalin, Diazepam/Valium, Hydrocodone, Xanax and Adderall. If
you used the prescription drug in its intended manner but without a proper prescription, it is not considered misuse for the purposes of this questionnaire. If
you used a prescription drug or over-the-counter drug for other than its intended purpose it is considered misuse. Personal use includes use with friends,
relatives, and family. Recreational use is defined as the sale or distribution, other than for personal use, not
intended for income or profit.
Have you misused prescription drugs or over-the-counter drugs?
No
Prescription Drugs and Over-the-Counter Drugs
Yes
If yes, provide: Your age when last misused:
The date when last misused:
Have you sold or distributed prescription drugs or over-the-counter drugs for recreational use?
No
If yes, provide: The date you last sold or distributed prescription drugs for recreational use:Yes
Have you sold or distributed prescription drugs or over-the-counter drugs for income or profit?
No
Yes
MM
YYYY
MM
YYYY
MM
YYYY
MM
YYYY
Drug History Questionnaire - Continuation
SSF 4099 (Rev. 04/21/2017) Page 3 of 4
MDMA, also known as Ecstasy or Molly, includes but is not limited to, synthetic drugs that alter mood and perception (awareness of surrounding objects and
conditions).
Have you used or purchased MDMA?
No
MDMA (Ecstasy or Molly)
If yes, provide: The date when last used or purchased:Yes
No
Yes
Have you sold, distributed or manufactured MDMA?
Cocaine is defined as cocaine other than crack cocaine.
Have you used or purchased cocaine?
No
Cocaine
If yes, provide: The date when last used or purchased:Yes
No
Yes
Have you sold, distributed or manufactured cocaine?
Hard drugs are defined by the 21 U.S.C. 812 - Controlled Substances Act of 1970 and include but are not limited to amphetamine, crack cocaine, heroin,
LSD, methamphetamine, various chemicals commonly found in hallucinogenic mushrooms, and Phencyclidine (PCP). The term "controlled substance"
means a drug or other substance, or immediate precursor. For the purpose of this question hard drugs does not include MDMA or cocaine.
Have you used or purchased hard drugs?
No
Hard Drugs Other than MDMA or Cocaine
Yes
No
Yes
Have you sold, distributed or manufactured a hard drug?
Enter your initials before going to the next page
MM
YYYY
MM
YYYY
A FALSE ANSWER TO ANY QUESTION IN THIS FORM MIGHT BE GROUNDS FOR DENYING APPOINTMENT OR FOR DISMISSAL
AFTER APPOINTMENT, AND MIGHT BE PUNISHABLE BY FINE OR IMPRISONMENT (18 U.S.C. 1001). ALL STATEMENTS OR
INFORMATION PROVIDED IN THIS FORM ARE SUBJECT TO INVESTIGATION TO INCLUDE A POLYGRAPH EXAMINATION.
Signature of Witness (U. S. Secret Service Employee Only)
Date Signed
Date SignedWitness' Division/Office
CERTIFICATION: I CERTIFY THAT ALL THE STATEMENTS MADE BY ME ON THIS FORM ARE TRUE, COMPLETE, AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND ARE MADE IN GOOD FAITH.
If you answered "Yes" to any of the above questions, provide a brief explanation in the space below and, if applicable, provide any compelling
mitigating circumstances.
PRIVACY ACT NOTICE
Authority to collect the information sought on the accompanying form is derived from the following sources: 5 U.S.C. 301; 18 U.S.C. 3056; Executive
Orders 10450, 12333, 12958, and 12968; 44 U.S.C., Chapter 35 and 31 CFR 2.1. The purpose of the information is to provide a basis for determining
employment eligibility for positions with access to classified documents. The information will be used to fulfill legal record keeping requirements as well
as referrals to other agencies on a need to know basis in their performance of duties. Submission of the information is voluntary. Failure to provide all or
any part of the requested information will not be used as a basis for denying any right, benefit, or privilege allowed by law. However, failure to provide
certain information may result in non-consideration for appointment or in termination on the basis of information in the record. Information provided on
this form will be kept confidential under provisions of the Privacy Act of 1974, 5 U.S.C. 552a.
ATTENTION: READ THE FOLLOWING CAREFULLY BEFORE SIGNING.
Printed Name of Applicant Signature of Applicant
SSF 4099 (Rev. 04/21/2017) Page 4 of 4
Drug History Questionnaire - Continuation
You may obtain more information about Selective Service requirements and procedures by contacting:
Selective Service
Registration Information Office
P.O. Box 94638
Palatine, IL 60094-4638
(847) 688-6888
TTY: 847-688-2567
http://www.sss.gov
STATEMENT OF SELECTIVE SERVICE
REGISTRATION STATUS
Signature of Individual Date Signed
SSF 3280 (09/2003)
If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law requires that you must
be registered with the Selective Service System, unless you meet certain exemptions under Selective Service law. If you are required
to register but knowingly and willfully fail to do so you are ineligible for appointment by executive agencies of the Federal Government.
(5 U.S.C. 3328)
CERTIFICATION OF REGISTRATIONS STATUS - Check one:
NON-REGISTRANTS UNDER AGE 26 - If you are under age 26 and have not registered as required, you should register promptly at a
United States Post Office, or consular office if you are outside the United States.
NON-REGISTRANTS AGE 26 AND OVER - If you were born in 1960 or later, are 26 years of age or older, and were required to
register but did not do so, you can no longer register under Selective Service law. Accordingly, you are not eligible for appointment to
an executive agency unless you can prove to the Office of Personnel Management (OPM) that your failure to register was neither
knowing nor willful. You may request an OPM decision through the Secret Service by returning this statement with your written request
for an OPM determination, together with any explanation and documentation you wish to furnish to prove that your failure to register
was neither knowing nor willful.
PRIVACY ACT STATEMENT - Because information on your registration status is essential for determining whether you are in
compliance with 5 U.S.C. 3328, failure to provide the information requested by this statement will prevent any further consideration of
your application for appointment. This information is subject to verification with the Selective Service System and may be furnished to
other Federal agencies for law enforcement or other authorized use in implementing this law.
FALSE STATEMENT NOTIFICATION - A false statement may be grounds for not hiring you, or for firing you if you have already begun
work. Also, you may be punished by fine or imprisonment. (18 U.S.C. 1001)
PERMISSION TO VERIFY STATUS - By signing below, you are granting the Secret Service permission to contact the Selective
Service System to verify your Selective Service registration status. (If you are completing and/or submitting this form through electronic
means, you may provide a signature by typing "/s/" followed by your name. Further endorsement may be required to validate this
information at a later point in the application process.)
I certify I am registered with the Selective Service System. (A copy of my Acknowledgement Letter or other proof of
registration issued by the Selective Service System is attached.) (If I previously served in the U.S. Armed Forced, a
copy of Form DD-214 is attached.)
I certify I have been determined by the Selective Service System to be exempt from the registration provisions of
Selective Service law. (A copy of my Exemption Letter or other proof of exemption issued by the Selective Service
System is attached.)
I certify I have not registered with the Selective Service System.
I certify I have not reached my 18th birthday and understand I am required by law to register at that time.
Page 1 of 1
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