PRE-APPOINTMENT CERTIFICATION STATEMENT
FOR SELECTIVE SERVICE REGISTRATION
Important Notice If you are a male born after December 31, 1959, and
are at least 18 years of age, civil service employment
law (5. U.S.C. 3328) requires that you must be
registered with the Selective Service System, unless
you meet certain exemptions under Selective Service
law. If you are required to register but knowingly
and willfully fail to do so, you are ineligible for
appointment by executive agencies of the Federal
Privacy Act Statement We need information on your registration with the
Selective Service System to see whether you are
affected by the laws we must follow in deciding who
may be employed by the Federal Government.
Criminal Penalty Statement A false statement by you may be grounds for not
hiring you or for firing you after you begin work.
Also, you may be punished by fine or imprisonment
(U.S. Code, Title 18, Section 1001).
( ) I certify that I am registered with the Selective Service System.
( ) I certify I have been determined by the Selective Service System
to be exempt from the registration provisions of Selective Service law.
( ) I certify I have not registered with the Selective Service System.
( ) I certify I have not reached my 18th birthday and understand I am
required by law to register at that time.
Legal signature (please use ink) Date signed (please use ink)
Link to Selective Service's On-Line Registration Information: https://www.sss.gov/regver/verification1.asp