SSS Form 404 and Instructions

SSS Volunteer Board Member Application

Personnel Policies and Procedures Manual - Chapter 521

Completing the attached information sheet does not obligate you to accept an appointment nor does it constitute an offer of an appointment. Everyone selected for recommendation will be contacted to determine suitability. This application is the first step in identifying individuals who are willing to serve as volunteer SSS board members.

The Selective Service System (SSS) is seeking applicants to serve as uncompensated SSS board members. There is no plan to begin inducting young men into the Armed Forces 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 the Agency select and train citizens who would be willing to serve if needed.

A. Eligibility Requirements: To be considered for appointment on an SSS board,

1. You MUST:

   1. be a citizen of the United States.

   2. be at least 18 years of age.

   3. reside in the county/borough/parish/municipality or Federal Judicial District in which the board has jurisdiction.

   4. be able to devote sufficient time to board affairs.

   5. be willing to apply the SSS law and regulations fairly and uniformly.

   6. be registered with the SSS, if required to do so.

2. You MAY NOT:

   1. be an active or retired member of the Armed Forces or any Reserve Component.

   2. have 20 or more cumulative years of prior SSS board membership.

   3. be an SSS employee, or immediate relative of (Relative is defined as a person who is connected to another by blood or marriage; Family is defined as any group of persons closely related by blood, as parents, siblings, children, uncles, aunts, and cousins):

      1. a compensated or uncompensated employee of the SSS;

      2. an Armed Forces or Reserve Component member assigned to the SSS; or

      3. an appointee to any other SSS board.

   4. have been convicted of any criminal act with a fine over $1,000.00; except if a conviction is (1) older than seven (7) years, (2) it was for a misdemeanor, and (3) you have since displayed outstanding integrity in the community.

2. Appointment: Local board members are appointed by the Director after recommendation by the Governor or comparable executive official of their State or Territory. Each SSS board is composed of multiple members, proportionately representative of the race and national origin of SSS registrants within its jurisdiction, to the maximum extent possible. No citizen shall be denied membership based on gender.

2. Selection: Individuals are selected by a process which begins with preliminary screening to determine whether the basic eligibility requirements are met. Personal interviews will be conducted with those persons found eligible. A potential 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 is required to sign an Oath of Office and Waiver of Pay.

2. Training: Each board member is required to complete training in members’ duties and responsibilities, as well as continuation training and/or exercises, which may be scheduled yearly. Board members’ training may also be kept current by various email communications. If board members are continuously unable to complete required training, they will be asked to resign or will be removed from their position.

2. Responsibilities: Board members are responsible for keeping abreast of changing regulations and procedures by attending training, meetings, and exercises as scheduled, to consider and decide SSS registrants’ claim(s) for deferment, exemption, or postponement from training and service. Decisions of local boards are subject to appeal.

2. Remuneration: Board members receive no compensation for serving on a board. However, travel reimbursement for expenses incurred while conducting SSS duties may be authorized with prior approval by the Director and / or the Associate Director for Operations. This includes travel to required training sessions and to board meetings. Remuneration will occur via direct deposit.

2. 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. Your state abbreviation corresponds to the relevant Region Headquarters.

REGION I REGION II REGION III

2834 Green Bay Road Building 922, Suite 202 84 N Aspen Street MS 26

Building 3400, Suite 276 1492 First Street Building 730, Room 140

North Chicago, IL 60064-9983 Dobbins ARB, GA 30069-5010 Buckley SFB, CO 80011-9526

CT, DE, DC, IL, IN, ME, MA, MD, MI, AL, AR, FL, GA, KY, LA, MS, NC, PR, AK, AZ, CA, CO, GU, HI, IA, ID, KS, MO,

NH, NJ, NY, OH, PA, RI, VT, or WI SC, TN, TX, VI, VA, or WV MN, MP, MT, NE, ND, NM, NV, OK, OR,

UT, SD, WA, WY, FM, AS, PW, or MH

SPECIFIC INSTRUCTIONS FOR SSS FORM 404

(Self-explanatory items are not mentioned below)

SSS estimates 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 Office of Management and Budget (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.

Item 1. Social Security Number: Use 9 digits no spaces.

Item 2. Title (Example: Dr. Mr. Ms. Mrs.), Last Name,

Suffix (Example: Jr., Sr., I, II, III), First Name, MI

Item 3. Sex: Select appropriate response

Item 5. Residence: Address (location) where you reside. Enter Number, Street, Apt. Number, City, County, State, and ZIP Code + 4: Fill in all 9 numbers. (You can find Zip+4 here: https://tools.usps.com/go/ZipLookupAction!input.action ). Enter home and mobile phone numbers and personal email address(es).

Item 6. Mailing: If address is the same as residence, enter “SAME”.

Item 7. Work/Employment Contact Information: Enter phone number, extension, fax, and email 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 select one or two boxes as appropriate on the application form.

Item 9a. Armed Forces Status: Please check one box only on the application form.

Item 9b. Military Discharge Type: Please check one box only on the application form.

Item 14. Former Board Member: If you have served as a board member before, fill in the location and dates of service if known.

Item 16. Males Only: If you are male and required to register, enter your Selective Service Number (you can find it here: https://www.sss.gov/verify/). Men born in March 1957 through December 1959 and March 1975 through June 1980 are exempt from the registration requirement and are considered in compliance.

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.

Selective Service System

Potential Volunteer Board Member Information

See Instructions and Privacy Statement (Page 2)

1. Social Security Number: ___________________

2. Title: ________ Last Name: ________________________ Suffix: ________ First Name: _______________ MI: ______

3. Sex: Male □ Female □

4. Birth Date: __ __ / __ __ / __ __ __ __ (MM/DD/YYYY)

5. Residence Address: _______________________________________________________________________________________

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

City: _________________ County: ____________________ State: ________ Zip +4: _____________

(9 Digit Zip Code Required)

Residence Phone: ___________________________ Mobile Phone: ________________­____

Personal Email: (required) ______________________ Secondary Email: __________________

6. Mailing Address: _____________________________________________________________________________________

(If same as residential address, enter “SAME.” Enter Number, Street, Apt. Number, City, State, and Zip+4.)

7. Employment/Work Contact Information: Work Phone: ____________________ Extension: _____________

Work Email: _____________________ Fax: __________________

(Please check one or more boxes as appropriate.)

8a. Ethnicity: □ Hispanic or Latino □ Not Hispanic or Latino

8b. Race: □ American Indian or Alaska Native □ Black or African American

□ Native Hawaiian or Other Pacific Islander □ Asian □ White

9a. Armed Forces Status : □ Not Applicable □ Active Duty □ Active National Guard / Reserve

□ Veteran □ Retired

9b. Military Discharge Type: □ Not Applicable □ Honorable □ General

□ Entry-Level Separation □ Medical □ Other than Honorable

□ Bad Conduct □ Dishonorable □ Dismissal (Officer Discharge)

YES NO (For Items 10 through 17 check ‘yes’ or ‘no’)

10. □ □ Are you a citizen of the United States?

11. □ □ Are you a compensated SSS employee or a spouse or family member of an SSS employee to include Armed Forces Members serving at SSS or an SSS board member? (Family is defined in the Eligibility Requirements on Page 1, paragraph A.2.c.).

12. □ □ Will you attend required board meetings, exercises, and training sessions, in person or via computer / remote technology method(s) as requested?

13. □ □ Do you feel you would be fair in performing the duties as a member of an SSS board?

14. □ □ Are you a former SSS board member? If yes, please indicate last known board information.

Board #: ________ State: _______ County: _______ Start Date: ___________ Stop Date: ____________

15. □ □ Have you been convicted of any criminal act with a fine over $1,000.00; except if a conviction is (1) older than seven (7) years, (2) it was for a misdemeanor, and (3) you have since displayed outstanding integrity in the community. If yes, explain below. _____________________________________________________________________________

_________________________________________________________________________________________

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

Selective Service Number: ___________________ (See Instructions, Page 2)

If NO, explain: _____________________________________________________________________________

I certify that all 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

SSS FORM 404 (MMM YYYY) Page 7 of 7 OMB Control Number #3240-0005