Form 402

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR APPOINTMENT

HS7

(PPPM)
PRIVACY ACT NOTICE

The authority for requesting the information in this form is the Military Selective Service Act (50 U.S.C. App 451 et seq.). The purpose is to
establish written authority for you to act officially and perform as a Selective Service System Registrar. This information may be used to
verify your official status and performance of duty to Federal, state, and local governmental agencies and the public. Furnishing the
information is voluntary, but failure to provide the information will preclude your appointment.
http://www.sss.gov/PDFs/Systeme/020or/020Records%202011.pdf

USE TYPEWRITER OR BALL POINT PEN

E

THIS SPACE IS FOR AGENCY USE ONLY

NAME (Last, First, Middle-Initial)

MR.

T MRS.

T ms.
BUSINESS PHONE:

DR.

n Other

BUSINESS FAX:

BUSINESS NAME AND ADDRESS (Business Name, No., Street, City, State or Foreign Country, ZIP Code)

BUSINESS EMAIL ADDRESS:
TO QUALIFY AS A REGISTRAR ONE MUST BE A U.S. CITIZEN, AT LEAST 18 YEARS OLD, AND REGISTERED WITH
THE SELECTIVE SERVICE SYSTEM, IF REQUIRED TO DO SO.

ARE YOU A U.S. CITIZEN?
YES

I-

NO E

n MALE

n FEMALE

r

DATE OF BIRTH:

NOMINATED REGISTRAR REPLACES (Where Applicable)

n

NAME:

I CERTIFY THAT I AM/WAS IN COMPLIANCE
WITH THE REGISTRATION REQUIREMENT OF
THE MILITARY SELECTIVE SERVICE ACT.

I AM/WAS NOT REQUIRED TO REGISTER
BECAUSE

(Last, First, Middle)

OATH OF OFFICE
I do solemnly sear (or affirm) that as a registrar 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 AND TRAVEL REIMBURSEMENT
I understand that I am a volunteer and that I will not receive any pay, travel reimbursement or compensation in any form for my services as a

volunteer registrar.

CERTIFICATION
I certify that the information I have provided on this form is true.

NOMINATED REGISTRAR'S SIGNATURE:
SSS FORM 402-A (APRIL 2012)

DATE:
OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
Uncompensated Registrar Appointment

High School Registrar Program (HS7)
Region I

Region II

Region III

Connecticut
Delaware
District of Columbia
Illinois
Indiana
Maine
Massachusetts
Michigan
New Hampshire
New Jersey
New York
New York City
Ohio
Pennsylvania
Rhode Island
Vermont
Wisconsin

Alabama
Arkansas
Florida
Georgia
Kentucky
Louisiana
Mississippi
North Carolina
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Virgin Islands
West Virginia

Alaska
Arizona
California
Colorado
Guam
Hawaii
Iowa
Idaho
Kansas
Minnesota
Missouri
Northern Mariana Islands
Montana
North Dakota
Nebraska
Nevada
New Mexico
Oklahoma
Oregon
South Dakota
Utah
Washington
Wyoming

Once you have completed and signed the SSS Form 402 (HS7) Uncompensated Registrar Appointment, please mail or fax
to your Selective Service System Region Headquarters. The addresses are as follows:
-

Selective Service System
Region I
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983
Fax (847) 688-3433

Selective Service System
Region II
2400 Lake Park Drive
Suite 270
Smyrna, GA 30080-8979
Fax (770) 319-5631

Selective Service System
Region III
3401 Quebec Street
Stapleton Bldg., #1014
Denver, CO 80207-2323
Fax (720) 941-1685

We estimate the public reporting burden for this collection will vary from two 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 (3240-0010), Arlington, VA 22209-2425. The OMB
control number 3240-0010, is currently valid. Persons are not required to respond to this collection unless it displays a valid
OMB control number.

SSS FORM 402-A (APRIL 2012)

OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR APPOINTMENT

UT1

(PPPM)
PRIVACY ACT NOTICE
The authority for requesting the information in this form is the Military Selective Service Act (50 U.S.C. App 451 et seq.). The purpose is to
establish written authority for you to act officially and perform as a Selective Service System Registrar. This information may be used to
verify your official status and performance of duty to Federal, state, and local governmental agencies and the public. Furnishing the
information is voluntary, but failure to provide the information will preclude your appointment.
http://www.sss.gov/PDFs/Systems%20of%20Records%202011.pdf
USE TYPEWRITER OR BALL POINT PEN

E
E
E
E

THIS SPACE IS FOR AGENCY USE ONLY

NAME (Last, First, Middle-Initial)

MR.
MRS.
MS.

BUSINESS PHONE:

DR.

I- Other

BUSINESS FAX:

BUSINESS NAME AND ADDRESS (Business Name, No., Street, City, State or Foreign Country, ZIP Code)

BUSINESS EMAIL ADDRESS:
TO QUALIFY AS A REGISTRAR ONE MUST BE A U.S. CITIZEN, AT LEAST 18 YEARS OLD, AND REGISTERED WITH
THE SELECTIVE SERVICE SYSTEM, IF REQUIRED TO DO SO.
ARE YOU A U.S. CITIZEN?

YES

I-

NO

I-

E

E

MALE

FEMALE

1---

I CERTIFY THAT I AM/WAS IN COMPLIANCE
WITH THE REGISTRATION REQUIREMENT OF
THE MILITARY SELECTIVE SERVICE ACT.

E

I AM/WAS NOT REQUIRED TO REGISTER
BECAUSE

DATE OF BIRTH:

NOMINATED REGISTRAR REPLACES (Where Applicable)
NAME:
(Last, First, Middle)

OATH OF OFFICE
I do solemnly sear (or affirm) that as a registrar 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 AND TRAVEL REIMBURSEMENT
I understand that I am a volunteer and that I will not receive any pay, travel reimbursement or compensation in any form for my services as a
volunteer registrar.

CERTIFICATION
I certify that the information I have provided on this form is true.

NOMINATED REGISTRAR'S SIGNATURE:
SSS FORM 402-B (APRIL 2012)

DATE:
OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
Uncompensated Registrar Appointment
Workforce Investment Act Registrar Program (UT1)

Region I

Region II

Region HI

Connecticut
Delaware
District of Columbia
Illinois
Indiana
Maine
Massachusetts
Michigan
New Hampshire
New Jersey
New York
New York City
Ohio
Pennsylvania
Rhode Island
Vermont
Wisconsin

Alabama
Arkansas
Florida
Georgia
Kentucky
Louisiana
Mississippi
North Carolina
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Virgin Islands
West Virginia

Alaska
Arizona
California
Colorado
Guam
Hawaii
Iowa
Idaho
Kansas
Minnesota
Missouri
Northern Mariana Islands
Montana
North Dakota
Nebraska
Nevada
New Mexico
Oklahoma
Oregon
South Dakota
Utah
Washington
Wyoming

Once you have completed and signed the SSS Form 402 (UT1) - Uncompensated Registrar Appointment, please mail or fax
to your Selective Service System Region Headquarters. The addresses are as follows:

Selective Service System
Region I
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983
Fax (847) 688-3433

Selective Service System
Region II
2400 Lake Park Drive
Suite 270
Smyrna, GA 30080-8979
Fax (770) 319-5631

Selective Service System
Region III
3401 Quebec Street
Stapleton Bldg., #1014
Denver, CO 80207-2323
Fax (720) 941-1685

We estimate the public reporting burden for this collection will vary from two 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 (3240-0010), Arlington, VA 22209-2425. The OMB
control number 3240-0010, is currently valid. Persons are not required to respond to this collection unless it displays a valid
OMB control number.

SSS FORM 402-B (APRIL 2012)

OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR APPOINTMENT
(PPPM)

SBR

PRIVACY ACT NOTICE
The authority for requesting the information in this form is the Military Selective Service Act (50 U.S.C. App 451 et seq.). The purpose is to
establish written authority for you to act officially and perform as a Selective Service System Registrar. This information may be used to
verify your official status and performance of duty to Federal, state, and local governmental agencies and the public. Furnishing the
information is voluntary, but failure to provide the information will preclude your appointment.
http://www.sss.gov/PDFs/Systems%20or/020Records%202011.pdf

USE TYPEWRITER OR BALL POINT PEN

n MR.
n MRS.
n MS.
n DR.
n Other

THIS SPACE IS FOR AGENCY USE ONLY

NAME (Last, First, Middle-Initial)

BUSINESS PHONE:
BUSINESS FAX:

BUSINESS NAME AND ADDRESS (Business Name, No., Street, City, State or Foreign Country, ZIP Code)

BUSINESS EMAIL ADDRESS:
TO QUALIFY AS A REGISTRAR ONE MUST BE A U.S. CITIZEN, AT LEAST 18 YEARS OLD, AND REGISTERED WITH

THE SELECTIVE SERVICE SYSTEM, IF REQUIRED TO DO SO.
ARE YOU A U.S. CITIZEN?
YES

I-

NO

E

n MALE

n FEMALE

r

DATE OF BIRTH:

NOMINATED REGISTRAR REPLACES (Where Applicable)

n

NAME:

I CERTIFY THAT I AM/WAS IN COMPLIANCE
WITH THE REGISTRATION REQUIREMENT OF
THE MILITARY SELECTIVE SERVICE ACT.

I AM/WAS NOT REQUIRED TO REGISTER

BECAUSE
(Last, First, Middle)

OATH OF OFFICE
I do solemnly sear (or affirm) that as a registrar 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 AND TRAVEL REIMBURSEMENT
I understand that I am a volunteer and that I will not receive any pay, travel reimbursement or compensation in any form for my services as a

volunteer registrar.

CERTIFICATION
I certify that the information I have provided on this form is true.

NOMINATED REGISTRAR'S SIGNATURE:
SSS FORM 402-D (APRIL 2012)

DATE:
OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
Uncompensated Registrar Appointment
Federal Bureau of Prisons Registrar Program (SBR)

Region I

Region II

Region HI

Connecticut
Delaware
District of Columbia
Illinois
Indiana
Maine
Massachusetts
Michigan
New Hampshire
New Jersey
New York
New York City
Ohio
Pennsylvania
Rhode Island
Vermont
Wisconsin

Alabama
Arkansas
Florida
Georgia
Kentucky
Louisiana
Mississippi
North Carolina
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Virgin Islands
West Virginia

Alaska
Arizona
California
Colorado
Guam
Hawaii
Iowa
Idaho
Kansas
Minnesota
Missouri
Northern Mariana Islands
Montana
North Dakota
Nebraska
Nevada
New Mexico
Oklahoma
Oregon
South Dakota
Utah
Washington
Wyoming

Once you have completed and signed the SSS Form 402 (SBR) - Uncompensated Registrar Appointment, please mail or fax
to your Selective Service System Region Headquarters. The addresses are as follows:

Selective Service System
Region I
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983
Fax (847) 688-3433

Selective Service System
Region II
2400 Lake Park Drive
Suite 270
Smyrna, GA 30080-8979
Fax (770) 319-5631

Selective Service System
Region III
3401 Quebec Street
Stapleton Bldg., #1014
Denver, CO 80207-2323
Fax (720) 941-1685

We estimate the public reporting burden for this collection will vary from two 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 (3240-0010), Arlington, VA 22209-2425. The OMB
control number 3240-0010, is currently valid. Persons are not required to respond to this collection unless it displays a valid
OMB control number.

SSS FORM 402-D (APRIL 2012)

OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR APPOINTMENT

STC

(PPPM)
PRIVACY ACT NOTICE
The authority for requesting the information in this form is the Military Selective Service Act (50 U.S.C. App 451 et seq.). The purpose is to
establish written authority for you to act officially and perform as a Selective Service System Registrar. This information may be used to
verify your official status and performance of duty to Federal, state, and local governmental agencies and the public. Furnishing the
information is voluntary, but failure to provide the information will preclude your appointment.
http://www.sss.gov/PDFs/Systems%20orY020Records °/0202011.pdf

USE TYPEWRITER OR BALL POINT PEN
THIS SPACE IS FOR AGENCY USE ONLY
NAME (Last, First, Middle Initial)

E MR.
E MRS.
EMS.

-

BUSINESS PHONE:

DR.

n Other

BUSINESS FAX:

BUSINESS NAME AND ADDRESS (Business Name, No., Street, City, State or Foreign Country, ZIP Code)

BUSINESS EMAIL ADDRESS:
TO QUALIFY AS A REGISTRAR ONE MUST BE A U.S. CITIZEN, AT LEAST 18 YEARS OLD, AND REGISTERED WITH
THE SELECTIVE SERVICE SYSTEM, IF REQUIRED TO DO SO.
ARE YOU A U.S. CITIZEN?
YES

I-

NO

I-

r MALE

n FEMALE

[---

I CERTIFY THAT I AM/WAS IN COMPLIANCE
WITH THE REGISTRATION REQUIREMENT OF
THE MILITARY SELECTIVE SERVICE ACT.

E

I AM/WAS NOT REQUIRED TO REGISTER
BECAUSE

DATE OF BIRTH:

NOMINATED REGISTRAR REPLACES (Where Applicable)
NAME:
(Last, First, Middle)

OATH OF OFFICE
I do solemnly sear (or affirm) that as a registrar 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 AND TRAVEL REIMBURSEMENT
I understand that I am a volunteer and that I will not receive any pay, travel reimbursement or compensation in any form for my services as a
volunteer registrar.

CERTIFICATION
I certify that the information I have provided on this form is true.

NOMINATED REGISTRAR'S SIGNATURE:
SSS FORM 402-E (APRIL 2012)

DATE:
OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
Uncompensated Registrar Appointment
State Correction Institutions Registrar Program (STC)
Region I

Region II

Region III

Connecticut
Delaware
District of Columbia
Illinois
Indiana
Maine
Massachusetts
Michigan
New Hampshire
New Jersey
New York
New York City
Ohio
Pennsylvania
Rhode Island
Vermont
Wisconsin

Alabama

Alaska
Arizona
California
Colorado
Guam
Hawaii
Iowa
Idaho
Kansas
Minnesota
Missouri
Northern Mariana Islands
Montana
North Dakota
Nebraska
Nevada
New Mexico
Oklahoma
Oregon
South Dakota
Utah
Washington
Wyoming

Arkansas
Florida
Georgia
Kentucky
Louisiana
Mississippi
North Carolina
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Virgin Islands
West Virginia

Once you have completed and signed the SSS Form 402 (STC) - Uncompensated Registrar Appointment, please mail or fax
to your Selective Service System Region Headquarters. The addresses are as follows:

Selective Service System
Region I
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983
Fax (847) 688-3433

Selective Service System
Region II
2400 Lake Park Drive
Suite 270
Smyrna, GA 30080-8979
Fax (770) 319-5631

Selective Service System
Region III
3401 Quebec Street
Stapleton Bldg., #1014
Denver, CO 80207-2323
Fax (720) 941-1685

We estimate the public reporting burden for this collection will vary from two 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 (3240-0010), Arlington, VA 22209-2425. The OMB
control number 3240-0010, is currently valid. Persons are not required to respond to this collection unless it displays a valid
OMB control number.

SSS FORM 402-E (APRIL 2012)

OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
UNCOMPENSATED REGISTRAR APPOINTMENT

FOP

(PPPM)
PRIVACY ACT NOTICE
The authority for requesting the information in this form is the Military Selective Service Act (50 U.S.C. App 451 et seq.). The purpose is to
establish written authority for you to act officially and perform as a Selective Service System Registrar. This information may be used to
verify your official status and performance of duty to Federal, state, and local governmental agencies and the public. Furnishing the
information is voluntary, but failure to provide the information will preclude your appointment.
http://www.sss.gov/PDFs/Systems%200 )/020Records%202011.pdf

E

MR.

r

MRS.

F

MS.

USE TYPEWRITER OR BALL POINT PEN
THIS SPACE IS FOR AGENCY USE ONLY
NAME (Last, First, Middle-Initial)

BUSINESS PHONE:

r DR.

BUSINESS FAX:

n Other

BUSINESS NAME AND ADDRESS (Business Name, No., Street, City, State or Foreign Country, ZIP Code)

BUSINESS EMAIL ADDRESS:
TO QUALIFY AS A REGISTRAR ONE MUST BE A U.S. CITIZEN, AT LEAST 18 YEARS OLD, AND REGISTERED WITH
THE SELECTIVE SERVICE SYSTEM, IF REQUIRED TO DO SO.

ARE YOU A U.S. CITIZEN?
YES r

NO

E

r

MALE

n FEMALE

1---

DATE OF BIRTH:

NOMINATED REGISTRAR REPLACES (Where Applicable)

r

NAME:

I CERTIFY THAT I AM/WAS IN COMPLIANCE
WITH THE REGISTRATION REQUIREMENT OF
THE MILITARY SELECTIVE SERVICE ACT.

I AM/WAS NOT REQUIRED TO REGISTER
BECAUSE

(Last, First, Middle)

OATH OF OFFICE
I do solemnly sear (or affirm) that as a registrar 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 AND TRAVEL REIMBURSEMENT
I understand that I am a volunteer and that I will not receive any pay, travel reimbursement or compensation in any form for my services as a
volunteer registrar.

CERTIFICATION
I certify that the information I have provided on this form is true.

NOMINATED REGISTRAR'S SIGNATURE:
SSS FORM 402-F (APRIL 2012)

DATE:
OMB Approval # 3240-0010

SELECTIVE SERVICE SYSTEM
Uncompensated Registrar Appointment
National Farm-Worker Jobs Registrar Program (FOP)

Region I

Region II

Region III

Connecticut
Delaware
District of Columbia
Illinois
Indiana
Maine
Massachusetts
Michigan
New Hampshire
New Jersey
New York
New York City
Ohio
Pennsylvania
Rhode Island
Vermont
Wisconsin

Alabama
Arkansas
Florida
Georgia
Kentucky
Louisiana
Mississippi
North Carolina
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Virgin Islands
West Virginia

Alaska
Arizona
California
Colorado
Guam
Hawaii
Iowa
Idaho
Kansas
Minnesota
Missouri
Northern Mariana Islands
Montana
North Dakota
Nebraska
Nevada
New Mexico
Oklahoma
Oregon
South Dakota
Utah
Washington
Wyoming

Once you have completed and signed the SSS Form 402 (FOP) - Uncompensated Registrar Appointment, please mail or fax
to your Selective Service System Region Headquarters. The addresses are as follows:

Selective Service System
Region I
2834 Green Bay Road
Building 3400, Suite 276
North Chicago, IL 60064-9983
Fax (847) 688-3433

Selective Service System
Region 11
2400 Lake Park Drive
Suite 270
Smyrna, GA 30080-8979
Fax (770) 319-5631

Selective Service System
Region III
3401 Quebec Street
Stapleton Bldg., #1014
Denver, CO 80207-2323
Fax (720) 941-1685

We estimate the public reporting burden for this collection will vary from two 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 (3240-0010), Arlington, VA 22209-2425. The OMB
control number 3240-0010, is currently valid. Persons are not required to respond to this collection unless it displays a valid
OMB control number.

SSS FORM 402-F (APRIL 2012)

OMB Approval # 3240-0010