Form 13172 Form 13172 Selective Service System Record Request

OMB Control No. 3095-0071
Expiration Date: 09-30-2018

SELECTIVE SERVICE SYSTEM RECORDS REQUEST
Year of Birth Prior to 1960
National Archives & Record Administration
National Archives – Saint Louis
ATTN: RL-SL
P.O. Box 38757
Saint Louis, MO 63138-0757

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

DO NOT PROVIDE CREDIT CARD INFORMATION. IF RECORDS ARE FOUND, YOU WILL RECEIVE AN INVOICE FOR PAYMENT.

*indicates Mandatory Information (Forms without mandatory information will be returned.)
A. REGISTRANT INFORMATION (PLEASE PRINT)
*Name:

_________________________
*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

B. RECORD REQUESTED
*Please check one block
✔

Registration Card
Classification Ledger
Registration Card AND Classification Ledger

C. REQUESTER CONTACT INFORMATION

(PLEASE PRINT)

*Name: ________________________________________

Telephone Number: _____________________________

________________________________________________ ______________________________ ______ ________
*Street Address
*City
*State *Zip Code
D. REQUESTER SIGNATURE
(only if Requester is the Registrant)____________________________________________________________________
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 (08-15)
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