Form 13172 Form 13172 Selective Service System Record Request

OMB Control No. 3095-0071
Expiration Date: 09–30–20XX

SELECTIVE SERVICE SYSTEM RECORDS REQUEST
Year of Birth Prior to 1960

National Archives & Records Administration
National Archives – Saint Louis
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 A REQUEST FOR PAYMENT

A. REGISTRANT INFORMATION (PLEASE PRINT)
Name:

______________________________
Last

___________________________
First

Selective Service Number (if known):

___________________

Date of Birth (MM/DD/YYYY):

_____________

__________________________
Middle

Home Address at Time of Registration: ______________________________________________________________
Street Address
_________________________________________________
City

_________________________________
County

_________
State

Place of Registration (if known): ____________________________________________________________________
Street Address
_________________________________________________ _________________________________
City
County
B. RECORD REQUESTED
Registration Card
Please check one block
Classification Ledger
Registration Card AND Classification Ledger
C. REQUEST PURPOSE

_________
State

D. CONTACT INFORMATION (PLEASE PRINT)
Name:

________________________________________ Telephone Number:

Email Address: _________________________________ Street Address:
City: __________________________________________ State:
E. REQUESTER SIGNATURE
(Only if the Requester is the Registrant)

__________________

_______________________________

___________ Zip Code:

_____________

PRIVACY ACT AND PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENTS

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. You are not
required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Public burden reporting for this collection of information is estimated to be two
minutes per response. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to National Archives and Records Administration (MP), 8601 Adelphi Road,
College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS
NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

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