Form SSS Form 404 SSS Form 404 Potential Board Member Information

SSS Board Member Application

Personnel Policies and Procedures Manual - Chapter 520
The Selective Service System (SSS) is seeking applicants to serve as uncompensated members of the SSS Boards. There is no plan to begin
inducting young men into military service at this time. Before inductions could be resumed, a law must be passed by Congress and approved by the President.
However, there is a need to make the SSS ready to operate should it become necessary. Consequently, it is necessary that we select and train citizens who
would be willing to serve if needed.
Completing the attached information sheet does not obligate you to accept an appointment nor does it constitute an offer of an appointment. Each
individual selected for recommendation will be contacted to determine availability. This application is the first step in identifying individuals who are willing to
serve as SSS Board Members.
A. Eligibility Requirements: In order to be considered for appointment on a Board,
1. You MUST:
(a) be a citizen of the United States;
(b) be at least 18 years of age;
(c) reside in the county in which the Board has jurisdiction;
(d) be able to devote sufficient time to accomplish Board Member duties;
(e) be willing to apply the SSS Law and Regulations fairly and uniformly; and
(f) be registered with the SSS, if required to do so.
2. You MAY NOT:
(a) be an active or retired member of the Armed Forces or any Reserve Component;
(b) have 20 or more cumulative years of prior SSS Board Membership;
(c) be employed by public or private enterprise which handles SSS matters;
(d) be a member of a law enforcement occupation as defined by SSS policy (example: police officer or judge);
(e) be a SSS employee or a spouse, parent or child of:
(1) a compensated or uncompensated employee of the SSS;
(2) a Reserve Officer assigned to the SSS; or
(3) an appointee to any other SSS Board.
(f) have been convicted, forfeited collateral, or are now under charges for a criminal offense, other than a traffic offense with only a fine
of $400.00 or less.

B. Appointment: Local Board Members are appointed by the Director after recommendation by the Governor of their State. District Appeal Board Members
are appointed by the Director upon recommendation of a Region Director. Each SSS Board is composed of 5 members and the membership of each Board
should, to the maximum extent possible, be proportionately representative of the race and national origin of the registrants within its jurisdiction.
No citizen will be denied membership based on gender.
C. Selection: Individuals are selected by a process which begins with preliminary screening to determine whether the basic eligibility requirements are
met. Personal interviews will be conducted with those persons found eligible. A prospective Board Member's indication of willingness to serve
by filling out the attached form is not a guarantee of a recommendation or a final commitment to serve. Each nominee will sign an Oath of Office
and Waiver of Pay and receive written confirmation of appointment before serving as a Board Member.
D. Training: Each Board Member may receive approximately 2 days initial training in members' duties and responsibilities, as well as continuation training
consisting of 4 hours, which may be scheduled yearly. Board Members training may also be kept current by various mailings. If Board Members
are unable to attend 3 consecutively scheduled training sessions, they will be asked to resign or will be removed from their positions.
E. Responsibilities: Board Members are responsible for keeping abreast of changing regulations and procedures by attending training and meeting as a
Board as scheduled, as often as necessary, to consider and decide on registrants' claim(s) for deferment, exemption and postponement of induction.
Decisions of Local Boards are subject to appeal. Because Board Members are key to the success of the SSS, they are asked to attend all training
sessions and Board meetings.
F. Remuneration: Board Members receive no pay for serving on the Board. They are, however, reimbursed for authorized travel expenses incurred while
conducting SSS Duties. This includes travel to required training sessions and to Board meetings. Remuneration will occur via Direct Deposit. Board
Members do receive satisfaction knowing that they have had a vital role in insuring that our nation's defense manpower needs have been met in a just
and impartial manner.
G. Application: If you meet the eligibility requirements in Section A and are interested in being considered for appointment, please complete the attached
form and give it to the assisting official present or forward it to the appropriate SSS Region Headquarters indicated below. Locate your state
abbreviation; this will designate the Region Headquarters address.
REGION I
CT, DE, DC, IL,IN, ME, MA, MD, MI,
NH,NJ,NY, OH, PA, RI, VT, or WI
Building 3400, Suite 276
2834 Green Bay Road
North Chicago, IL 60064-9983

REGION II
AL, AR, FL, GA, KY, LA, MS, NC, PR, SC, TN,
TX, VI, VA, or WV
2400 Lake Park Drive, Suite 270
Smyrna, GA 30080

REGION III
AK, AZ, CA, CO, GU, HI, IA, ID, KS, MO, MN,
MP, MT, NE, ND, NM, NV, OK, OR, SD, UT,
WA, or WY
Stapleton Building, Suite 1014
3401 Quebec Street
Denver, CO 80207-2323

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SPECIFIC INSTRUCTIONS FOR SSS FORM 404
(Self explanatory items are not mentioned below)

Item 1.

Social Security Number: Use 9 digits.

Item 2.

Title: Enter a one digit number: 1= Mr,. 2 = Mrs., 3 = Ms., 4 = Miss., 5 = Dr., 6 = Other.
Suffix: Example: Jr., Sr., I, II, III.

Item 3.

Residence: Address (location) where you reside. Enter Number, Street, Route, Apt. Number, city, county, state.
ZIP: Fill in all 9 numbers.

Item 4.
Item 5.

Mailing: If address is the same as residence, write "SAME".
Residence-Business Phones/E-mail/Fax: Enter phones followed by your primary e-mail and Fax if applicable.

Item 8.

Race/Ethnic: Enter a one digit number from the list below, followed by "H" for Hispanic or "N" for Non-Hispanic Origin.
Zip: Fill in all 9 numbers.
First Box: 1 = American Indian/Alaskan 2 = Asian/Pacific Islander 3 = Black 4 = White
Second Box: H = Hispanic N = Non-Hispanic Example: 4H = White Hispanic

Item 10.

Armed Forces Status: Enter a one digit number form the list below:
1=Non Applicable 3=Active National Guard/Reserve
2=Active Duty
4=Inactive Reserve

5=Retired
6=Honorable discharge, not retired

7=Other than honorable, not retired.
8=Type of discharge unknown

Item 13.

Family or Personal Connection with SSS: See Item A.2.(e), on page one.

Item 17.

Former Board Member: If you have served as a Board Member before, fill in the location and dates of service. If you have
additional previous tours of service, use the continuation sheet.

Item 19.

Males Only: If you are male and required to register, enter your Selective Service Number.

Item 20.

Occupation: Enter a two-digit number code from the list below. You may enter further information in the space provided. If you
choose "Other - 99", enter your occupation in the space provided at Item 20.
01=Accounting
02=Banking
03=Education
04=Agriculture
05=Government
06=Insurance

Item 21.

12=Real Estate
13=Retired
14=Sales
15=Self Employed
16=Trades
17=Student

18=Engineering
19=Computer/Data Processing
20=Retail
99=Other (Specify)

Occupational Category: Enter a two-digit number code from the list below. You may enter further information in the space provided.
If you enter numbers 23, 24, or 25, enter a description in the space provided in Item 21.
01=Asst. Attorney General
02=Asst. District Attorney
03=Attorney General
04=Bail Commissioner
05=Circuit Court Judge
06=County Attorney
07=County Judge
08=Court Warrant Officer
09=Court Bailiff
10=Deputy Sheriff

Item 22.

07=Legal
08=Homemaker
09=Manufacturing
10=Medical/Dental
11=Secretary/Clerical

11=District Attorney
12=District Judge
13=Justice of the Peace
14=Magistrate
15=Mayor (w/Judicial Duties)
16=Police Court Judge
17=Police Justice
18=Police Officer
19=Parole/Probation Officer
20=Prosecuting Attorney

21=Sheriff
22=States Attorney
23=Judicial (Specify)
24=Penal (Specify)
25=Law Enforcement (Specify)
26=Other
99=None of the Above

Civic/Professional Organizations: If you belong to any civic/professional organizations enter name of Organization and office
held. Use the continuation sheet as needed.
PRIVACY ACT STATEMENT

THE INFORMATION REQUESTED ON THIS FORM IS UNDER AUTHORITY OF SECTION 10(b)(3) OF THE MILITARY SELECTIVE SERVICE ACT (50 U.S.C APP.460(b)(3)).
FURNISHING THE INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE THE REQUESTED INFORMATION WILL PRECLUDE SELECTION FOR APPOINTMENT.
INFORMATION SUPPLIED ON THIS FORM WILL BE USED IN SELECTING AND APPOINTING MEMBERS OF THE LOCAL BOARDS, AND DISTRICT APPEAL BOARDS OF
THE SELECTIVE SERVICE SYSTEM. INFORMATION SUPPLIED MAY BE FURNISHED TO THE DEPARTMENT OF JUSTICE WHEN REQUIRED IN CONNECTION WITH
PROCESSING ALLEGED VIOLATIONS OF THE MILITARY SELECTIVE SERVICE ACT OR TITLE 18 U.S.C
THE NAME AND COUNTY OF RESIDENCE OF PERSONS APPOINTED AS MEMBERS OF BOARDS WILL BE PUBLIC INFORMATION.

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SELECTIVE SERVICE SYSTEM

FOR OFFICE USE ONLY
ST:___ AO#___ LB#___

Potential Board Member Information

Service Computation Date ___/___/______

See Instructions and Privacy Statement (Page 2).
1. Social Security Number:
2. Title:

Last Name:

3. Residence Address:
City:

Suffix:

First Name:

MI:

(Enter Number, Street, Route, Apt., number where you reside. Please no P.O. Box.)

County:

State:

Zip:

(9 Digit Zip Required)

4. Mailing Address:
City:

State:

5. Residence Phone:

Zip:

Employer:

6. Business Phone:

E-mail:

Extension:

Fax:

7. Birth Date:
Month / Day / Year

8. Race/Ethnic:
(See Instructions on Page 2)

10. Are you a member of the Armed Forces of the United States? Enter Number:
YES
NO (For Items 11 through 19, check 'yes' or 'no'.)

9. Sex: Male

Female

(See Instructions - Page 2)

11.

Are you a citizen of the United States?

12.

Are you a compensated employee of the Selective Service System?

13.

Are you a spouse of an employee of Selective Service, as defined in the Eligibility Requirements
on Page 1, paragraph A.2.e.?

14.

Are you (or are you the spouse of) a Reserve Force Officer with Selective Service, or an appointee
to another Selective Service board?

15.

Will you attend required board meetings and training sessions?

16.

Do you feel you would be objective and unbiased in performing the duties as a member of a
Selective Service board?

17.

Are you a former Selective Service Board Member? (Use continuation sheet if necessary)
Start Date:
City:
If yes: Board No:
Stop Date:
County:
State:

18.

Have you ever been convicted, forfeited collateral, or are now under charges for a criminal
offense, other than traffic offense with only a fine of $400.00 or less? If yes, explain below.

19.

Males only: I certify that I am in compliance with the registration requirement of the Military
Selective Service Act. If no, explain below. Selective Service Number:

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20. Occupation: (See Instructions, Page 2)

Other:

21. Occupational Category: (See Instructions, Page 2)

Description:

22. I belong to the following civic/professional organizations: (If additional space is needed, use continuation sheet).
Organization

Office Held (if any)

I certify that all of the statements made above are true, complete, and correct to the best of my knowledge and belief, and are
made in good faith.
DATE SIGNED (SIGN IN INK)

SIGNATURE OF POTENTIAL BOARD MEMBER

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SELECTIVE SERVICE SYSTEM

OATH OF OFFICE AND WAIVER OF PAY
(Required of every person who undertakes to render voluntary uncompensated service in the
administration of the Military Selective Service Act)

OATH OF OFFICE
I do solemnly swear (or affirm) that if appointed to any position under the Military Selective Service Act, I will support and defend
the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the
same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully
discharge the duties of the office on which I am about to enter; SO HELP ME GOD.

WAIVER OF PAY
I hereby expressly declare that I am volunteering my services to assist in the administration of the Military Selective Service Act,
and if appointed to an uncompensated position, I hereby expressly waive any right to pay or compensation in any form
whatsoever for services heretofore or hereafter rendered. This waiver is signed by me pursuant to the provisions of the
Selective Service Regulations.
Printed or Typed Full Name

Signature

Date

AUTHENTICATION
SUBSCRIBED AND SWORN (or affirmed) BEFORE ME ON THIS

Printed or Typed Full Name and Title of Individual Authorized to Administer Oath

DAY OF

20

Signature

Instructions

-

Completing this portion of the Form 404 will not commit you to accept an appointment nor does it constitute
an offer of appointment.
Oath of Office and Waiver of Pay - To be completed and signed by the prospective applicant when
completing the interview and the first portion of this form.
Authentication - To be completed and signed by the person so authorized in Chapter 520, PPPM, after the
prospective applicant has signed the Oath of Office and Waiver of Pay.
This form will be retained in the Board Member's file.

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SELECTIVE SERVICE SYSTEM
Potential Board Member Information
Continuation Sheet
17. Additional former Selective Service Board member:
Board No:
City:

Start Date:

State:

County:

Stop Date:

Board No:

City:

Start Date:

State:

County:

Stop Date:

Board No:

City:

Start Date:

State:

County:

Stop Date:

22. Additional civic/professional organizations:
Organization

Office Held (if any)