Form 13172e Form 13172e Selective Service System Record Request

OMB Control No. 3095-0071
Expiration Date: 06-30-2015

SELECTIVE SERVICE SYSTEM RECORDS REQUEST
Year of Birth Prior to 1960
Provide the following information on the registrant and mail this form with any attachments to:
National Archives & Record Administration
National Archives – Saint Louis
ATTN: RL-SL
P.O. Box 38757
Saint Louis, MO 63138-0757
DO NOT PROVIDE CREDIT CARD INFORMATION; IF RECORDS ARE FOUND, YOU WILL RECEIVE AN INVOICE FOR PAYMENT

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
Place of Registration (if known):

____________________________________________________________
Street Address
________________________ ____________________
City
County

* Record Requested (please check one):

____________
State

____________
State

Registration Card
Classification Ledger
Registration Card AND Classification Ledger

* Contact Information:
Name: _________________________________

Telephone Number: _______________________

Address: _________________________________________________
Street Address
_______________________________ _____ __________
City
State Zip Code

* Mandatory Information – Forms without mandatory information will be returned.
PRIVACY ACT STATEMENT
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.
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION
NA FORM 13172 (01-15)
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