Form SSS Form 402 SSS Form 402 Uncompensated Registrar Appointment

AGENCY USE ONLY

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR
APPOINTMENT FORM

CONTROL NUMBER

PRIVACY ACT NOTICE
The authority for requesting the information on this form is the Military Selective Service Act (50 U.S.C. App 3801 et seq.). The purpose is to
establish written authority for you to act officially and perform as a Selective Service System Registrar. This information may be used to verify your
official status and performance of duty to Federal, State, and local governmental agencies and the public. Furnishing the information is voluntary,
but failure to provide the information will preclude your appointment.

REGISTRAR
PROGRAM

High School (HS7)
Workforce Innovation & Opportunity Act (UT1)
National Farm-Workers Job (FOP)

Federal Bureau of Prisons (SBR)
State Correction Institutions (STC)
Other:

TO QUALIFY AS A REGISTRAR ONE MUST BE A U.S. CITIZEN, AT LEAST 18 YEARS OLD, AND
REGISTERED WITH THE SELECTIVE SERVICE SYSTEM, IF REQUIRED TO DO SO.
Title

Last Name

Sex:

Suffix

First Name

Are you a U.S. Citizen?

Male
Female

Date of Birth: ________________________

MI

Yes
No

I certify that I am registered with Selective Service.

Month / Date / Year

I certify that I am exempt from Selective Service registration
because I am a female.
I certify that I am NOT registered with Selective Service.
Explain:

Business Name:
Address (Number, Street, City, State or Foreign Country, ZIP Code – Please no P.O.Box)

This Appointment Replaces (If Known – Last Name, First Name, MI)
OATH OF OFFICE
I do solemnly swear (or affirm) that as a registrar under the Military Selective Service Act, I will support and defend the Constitution of 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 AND TRAVEL REIMBURSEMENT

I understand that I am a volunteer and that I will not receive any pay, travel reimbursement or compensation in any form for my services as a volunteer.

CERTIFICATION
I certify that the information I have provided on this form is true.
NOMINATED REGISTRAR’S SIGNATURE:
SSS FORM 402 (NOV 2016)

DATE:
OMB Control Number #3240-0010

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR
APPOINTMENT FORM
Once you have completed and signed the SSS FORM 402 (Uncompensated Registrar Appointment Form), please mail or fax to your
Selective Service Region Headquarters. The addresses are as follows:
Selective Service System
Region I
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983

Selective Service System
Region II
1492 First Street
Building 922, Suite 202
Dobbins ARB, GA 30069-5010

Selective Service System
Region III
84 N Aspen Street MS 26
Building 730, Room 140
Buckley AFB, CO 80011-9526

Fax (847) 688-3433

Fax (678)655-9594

Fax (720) 847-4210

Connecticut
Delaware
District of Columbia
Illinois
Indiana
Maine
Massachusetts
Michigan
New Hampshire
New Jersey
New York
New York City
Ohio
Pennsylvania
Rhode Island
Vermont
Wisconsin

Alabama
Arkansas
Florida
Georgia
Kentucky
Louisiana
Mississippi
North Carolina
South Carolina
Tennessee
Texas
Virginia
West Virginia

Alaska
Arizona
California
Colorado
Hawaii
Iowa
Idaho
Kansas
Minnesota
Missouri
Montana
North Dakota
Nebraska
Nevada
New Mexico
Oklahoma
Oregon
South Dakota
Utah
Washington
Wyoming

Puerto Rico
Virgin Islands

Guam
Northern Mariana Islands

We estimate the public reporting burden for this collection will vary from two minutes per response, including time for reviewing
instructions, searching existing data sources, gathering data, and completing and reviewing the information. Send comments
regarding the burden statement or any further aspects of the collection of information, including suggestions for reducing this burden
to: Selective Service System, SSS Forms Officer (3240-0010), Arlington, VA 22209-2425. The OMB control number 3440-0010, is
currently valid. Persons are not required to respond to this collection unless it displays a valid OMB control number.

SSS FORM 402 (NOV 2016)

OMB Control Number #3240-0010