Form 13172 Form 13172 Selective Service Record Request

OMB Control No. 3095-00XX

Expiration date: XX-XX-2015

SELECTIVE SERVICE RECORD REQUEST

Year of Birth Prior to 1960

Provide the following information on the registrant and mail this form together with any attachments to:

National Archives & Records Administration

National Archives at St. Louis

ATTN: RL-SL

P.O. Box 38757

St. Louis, MO 63138-0757

PLEASE PRINT

* Name of Registrant: _______________________ _______________________ _______________________

(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)

* Information Requested/Reason for Request:

* Contact Information:

Name: _______________________________________________________________

Street Address: _______________________________________________________________

City, State, Zip Code: _______________________________________________________________

Telephone Number: _______________________________________________________________

* Mandatory Information – Forms without mandatory information will be returned.

PRIVACY ACT STATEMENT

Collections of this information is authorized by 44 U.S.C. 2104(a). Disclosure of the 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 about the records. The information is used by NARA employees to search for the record, to respond to you, to maintain control over information requests received and answered, and to facilitate preparation of internal statistical reports. If you provide credit card information, that information is used to bill you for copies.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION NA Form 13172 (01-11)