Form 404 Potential Board Member Information

SSS Board Member Application
Personnel Policies and Procedures Manual - Chapter 520
The Selective Service System (SSS) is seeking applicants to serve as uncompensated members of the SSS Boards. There is no plan to begin inducting
young men into military service at this time. Before inductions could be resumed, a law must be passed by Congress and approved by the President. However,
there is a need to make the SSS ready to operate should it become necessary. Consequently, it is necessary that we select and train citizens who would be
willing to serve if needed.

Completing the attached information sheet does not obligate you to accept an appointment nor does it constitute an offer of an appointment. Each individual
selected for recommendation will be contacted to determine availability. This application is the first step in identifying individuals who are willing to serve as SSS
Board Members.
A.

Eligibility Requirements: In order to be considered for appointment on a Board,
1.

You MUST:
a. be a citizen of the United States;
b. be at least 18 years of age;
c. reside in the county in which the Board has jurisdiction;
d. be able to devote sufficient time to accomplish Board Member duties;
e. be willing to apply the SSS law and Regulations fairly and uniformly; and
f.
be registered with the SSS, if required to do so.

2.

You MAY NOT:
a. be an active or retired member of the Armed Forces or any Reserve Component;
b. have 20 or more cumulative years of prior SSS Board Membership;
c. be employed by public or private enterprise which handles SSS matters;
d. be a member of a law enforcement occupation as defined by SSS policy (example: police officer or judge);
e. be a SSS employee or a spouse of:
i. a compensated or uncompensated employee of the SSS;
ii. a Reserve Officer assigned to the SSS; or
iii. an appointee to any other SSS Board.
f.
have been convicted, forfeited collateral, or are now under changes for a criminal offense, other than a traffic offense with only a
fine of $400.00 or less; except if a conviction is (1) older than 10 years (2) it was for a misdemeanor, and (3) the person has since
displayed outstanding integrity in the community.

B.

Appointment: Local Board Members are appointed by the Director after recommendation by the Governor of their State. District Appeal Board
Members are appointed by the Director upon recommendation of a Region Director. Each SSS Board is composed of five members and membership of
each Board should, to the maximum extent possible, be proportionately representative of the race and national origin of the registrants within its
jurisdiction. No citizen will be denied membership based on gender.

C.

Selection: Individuals are selected by a process which begins with preliminary screening to determine where the basic eligibility requirements are met.
Personal interviews will be conducted with those persons found eligible. A prospective Board Member’s indication of willingness to serve by filling out
the attached form is not a guarantee of a recommendation or a final commitment to serve. Each nominee will sign an Oath of Office and Waiver of Pay
and receive written confirmation of appointment before serving as a Board Member.

D.

Training: Each Board Member may receive approximately five hours initial training in members’ duties and responsibilities, as well as continuation
training consisting of two hours, which may be scheduled yearly. Board Members training may also be kept current by various mailings. If Board
Members are unable to attend three consecutively scheduled training sessions, they will be asked to resign or will be removed from their positions.

E.

Responsibilities: Board Members are responsible for keeping abreast of changing regulations and procedures by attending training and meeting as a
Board as scheduled, as often as necessary, to consider and decide on Registrants’ claim(s) for deferment, exemption and postponement of induction.
Decisions of Local Boards are subject to appeal. Because Board Members are key to the success of the SSS, they are asked to attend all training
sessions and Board meetings.

F.

Remuneration: Board Members receive no pay for serving on the Board. They are, however, reimbursed for authorized travel expenses incurred while
conducting SSS Duties. This includes travel to required training sessions and to Board meetings. Remuneration will occur via Direct Deposit.

G.

Application: If you meet the eligibility requirements in Section A and are interested in being considered for appointment, please complete the attached
form and give it to the assisting official present or forward it to the appropriate SSS Region Headquarters indicated below. Locate your state
abbreviation; this will designate the Region Headquarters address.
REGION I
CT, DE, DC, IL, IN, ME, MA, MD, MI,
NH, NJ, NY, OH, PA, RI, VT, or WI
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983

REGION II
AL, AR, FL, GA, KY, LA, MS, NC, PR, SC, TN,
TX, VI, VA, or WV
Building 922, Suite 202
1492 First Street
Dobbins ARB, GA 30069-5010

REGION III
AK, AZ, CA, CO, GU, HI, IA, ID, KS, MO, MN,
MP, MT, NE, ND, NM, NV, OK, OR, SD, UT
WA, or WY
84 N Aspen Street MS 26
Building 730, Room 140
Buckley AFB, CO 80011-9526

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SSS FORM 404 (NOV 2016)

OMB Control Number #3240-0005

SPECIFIC INSTRUCTIONS FOR SSS FORM 404
(Self explanatory items are not mentioned below)

Item 1.

Social Security Number: Use 9 digits.

Item 2.

Suffix: Example: Jr., Sr., I, II, III

Item 3.

Sex: Circle appropriate response.

Item 5.

Residence: Address (location) where you reside. Enter Number, Street, Route, Apt. Number, city, county, state.
ZIP: Fill in all nine numbers.

Item 6.

Mailing: If address is the same as residence, write “SAME”.

Item 7.

Residence-Business Phone/E-mail/Fax: Enter phone number followed by your primary e-mail and fax if applicable.

Item 8a. Ethnicity: Do you consider yourself to be Hispanic or Latino? Please check one box only on the application form.
Item 8b. Race: What is your race? Please check one or more boxes as appropriate on the application form.
Item 9.

Armed Forces Status: Please check one box only on the application form.

Item 17. Former Board Member: If you have served as a Board Member before, fill in the location and dates of service. If you have additional
previous tours of service use the continuation sheet.
Item 18. Males Only: If you are male and require to register, enter your Selective Service Number.
Item 19. Law Enforcement Occupational Category: Enter a two-digit number code from the list below. You may enter further information in the space
provided. If you enter numbers 23, 24, or 25, enter a description in the space provided in item 20.
01 = Asst. Attorney General
02 = Asst. District Attorney
03 = Attorney General
04 = Bail Commissioner
05 = Circuit Court Judge
06 = Court Attorney
07 = County Judge
08 = Court Warrant Officer
09 = Court Bailiff
10 = Deputy Sheriff

11 = District Attorney
12 = District Judge
13 = Justice of the Peace
14 = Magistrate
15 = Mayor (w/Judicial Duties)
16 = Police Court Judge
17 = Police
18 = Police Officer
19 = Parole/Probation Officer
20 = Prosecuting Attorney

21 = Sheriff
22 = State Attorney
23 = Judicial (Specify)
24 = Penal (Specify)
25 = Law Enforcement (Specify)
26 = Other _________________
99 = None of the Above

Item 20. Occupation: Enter a two - digit number code from the list below. You may enter further information in the space provided. If you choose
“Other – 99”, enter your occupation in the space provided at Item 19.
01 = Accounting
02 = Banking
03 = Education
04 = Agriculture
05 = Government
06 = Insurance

07 = Legal
08 = Homemaker
09 = Manufacturing
10 = Medical/Dental
11 = Secretary/Clerical

12 =1 Real Estate
13 = Retired
14 = Sales
15 = Self Employed
16 = Trades
17 = Student

18 = Engineering
19 = Computer/Data Processing
20 = Retail
99 = Other (Specify)

Item 21. Civic/Professional Organizations: If you belong to any civic/professional organizations enter name of Organization and office held. Use the
Continuation sheet as needed.

PRIVACY ACT STATEMENT
THE INFORMATION REQUESTED ON THIS FORM IS UNDER AUTHORITY OF SECTION 10(b)(3) OF THE MILITARY SELECTIVE SERVICE ACT (50
U.S.C APP 460(b)(3)). FURNISHING THE INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE THE REQUESTED INFORMATION WILL
PRECLUDE SELECTION FOR APPOINTMENT.
INFORMATION SUPPLIED ON THIS FORM WILL BE USED IN SELECTING AND APPOINTING MEMBERS OF THE LOCAL BOARDS AND DISTRICT
APPEAL BOARDS OF THE SELECTIVE SERVICE SYSTEM. INFORMATION SUPPLIED MAY BE FURNISHED TO THE DEPARTMENT OF JUSTICE
WHEN REQUIRED IN CONNECTION WITH PROCESSING ALLEGED VIOLATIONS OF THE MILITARY SELECTIVE SERVICE ACT OR TITLE 18 U.S.C.
THE NAME AND COUNTY OF RESIDENCE OF PERSONS APPOINTED AS MEMBERS OF BOARDS WILL BE PUBLIC INFORMATION.

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SSS FORM 404 (NOV 2016)

OMB Control Number #3240-0005

Selective Service System
Potential Board Member Information
See Instructions and Privacy Statement (Page2)
1.

Social Security Number: __ __ __ - __ __ - __ __ __ __

2.

Title: ________ Last Name: ________________________ Suffix: ________ First Name: _______________

3.

Sex:

4.

Birth Date: __ __ / __ __ / __ __ __ __ (Month/Day/Year)

5.

Residence Address:

Male

Female

MI: ______

(Circle One)

________________________________________________________________________________
(Enter Number, Street, Route, Apt., number where you reside. Please no P.O Box)

City: ____________________________ County: ____________________ State: __________ Zip: ___________________
(9 Digit Zip Requested)

6.

Residence Phone: ___________________

Mobile Phone: ___________________

E-Mail Address: ____________________________

Secondary E-Mail: _____________________________________

Mailing Address: _________________________________________________________________
City: ____________________________ State: ___________ Zip: _____________

7.

Employer: _______________________
Business Phone: _____________________________ Extension: _________
Work E-mail: ___________________________________________ Fax: _________________________

(Please check one or more boxes as appropriate.)

8a. Ethnicity:
8b. Race:

9.

Hispanic or Latino
American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Islander

Asian

Armed Forces Status:

YES

NO

Not Hispanic or Latino

White

Non Applicable

Active Duty

Active National Guard/Reserve

Inactive National Guard/Reserve

Retired

Honorable Discharge

Other than Honorable, not Retired

Type of Discharge unknown

(For Items 11 through 18 check ‘yes’ or ‘no’)

10.

Are you a citizen of the United States?

11.

Are you a compensated employee of the Selective Service System?

12.

Are you a spouse of an employee of Selective Service, as defined in the Eligibility Requirements on Page 1, paragraph
A.2.e?

13.

Are you (or are you the spouse of) a Reserve Force Officer with Selective Service, or an appointee to another Selective
Service board?

14.

Will you attend required board meetings and training sessions?

15.

Do you feel you would be objective and unbiased in performing the duties as a member of a Selective Service Board?

16.

Are you a former Selective Service Board Member? (Use continuation sheet if necessary)
If yes: Board No: __________

City: ____________________________

Start Date: ____________

State: __________

County: __________________________

Stop Date: _____________

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SSS FORM 404 (NOV 2016)

OMB Control Number #3240-0005

YES

NO

17.

(For Items 11 through 18 check ‘yes’ or ‘no’)

Have you ever been convicted, forfeited collateral, or are now under charges for a criminal offense, other than traffic
offense with only a fine of $400.00 or less? If yes, explain below.

___________________________________________________________________________________
18.

MALES ONLY: I certify that I am in compliance with the registration requirement of the Military Selective Service Act.
Selective Service Number:

__ __ - __ __ __ __ __ __ __ - __

If NO, explain: _____________________________________________________________________________

_____________________________________________________________________
19.

Are you a member of the Law Enforcement community?
If YES: Occupation Category: __ __

_________________ Description: _______________________________
(See Instructions Page 2)

20. Occupation:

__ __

________________ If Other: _______________________________
(See Instruction, Page 2)

If Government, explain: ______________________________________________________________________

_______________________________________________________________
21. I belong to the following Civic/Professional Organizations: (If additional space is needed, use continuation sheet)
Organization:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Office Held (if any):
_____________________________________________________________________________________________
_____________________________________________________________________________________________

I certify that all of the statements made above are true, complete, and correct to the best of my knowledge and belief, and are made in good
faith.
___________________________
_______________________________________________________
DATE SIGNED (SIGN IN INK)
SIGNATURE OF POTENTIAL BOARD MEMBER

We estimate the public reporting burden for this collection will vary from 5 to 15 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 other aspects of the collection of information, including suggestions for reducing this burden to: Selective Service
System, SSS Forms Officer (3240-0005), Arlington, VA 22209-2425. The OMB control number 3240-0005 is currently valid. Persons are not
required to respond to this collection unless it displays a valid OMB control number.
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SSS FORM 404 (NOV 2016)

OMB Control Number #3240-0005

Selective Service System
OATH OF OFFICE AND WAIVER OF PAY
(Required of every person who undertakes to render voluntary uncompensated service in the administration of the Military
Selective Service Act)

OATH OF OFFICE
I do solemnly swear (or affirm) that if appointed to any position under the Military Selective Service Act, I will support and defend
the Constitution of the 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
I hereby expressly declare that I am volunteering my services to assist in the administration of the Military Selective Service Act,
and if appointed to an uncompensated position, I hereby expressly waive any right to pay or compensation in any form
whatsoever for services heretofore or hereafter rendered. This waiver is signed by me pursuant to the provisions of the
Selective Service Regulations.
Printed or Typed Full Name

Signature

Date

AUTHENTICATION
SUBSCRIBED AND SWORN (or affirmed) BEFORE ME ON THIS

______ DAY OF ___________________ 20_____

Printed or Typed Full Name and Title of Individual Authorized to Administer Oath

Signature

INSTRUCTIONS
−
−
−

−

Completing this portion of the Form 404 will not commit you to accept an appointment nor does it constitute and offer of
appointment.
Oath of Office and Waiver of Pay – To be completed and signed by the prospective applicant when completing the
interview and the first portion of this form.
Authentication – To be completed and signed by the person so authorized in Chapter 520, PPPM, after the
prospective applicant has signed the Oath of Office and Waiver of Pay.
This form will be retained in the Board Member’s file.
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SSS FORM 404 (NOV 2016)

OMB Control Number #3240-0005