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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

Government.

 

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).

 

 

CERTIFICATION OF REGISTRATION STATUS

 

( ) 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

 

 

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