Selective Service Form printable pdf download

Selective Service Form

Human Resources & Payroll

4400 University Drive, MS 3C3, Fairfax, Virginia 22030

Phone: 703-993-2600; Fax: 703-993-2601

Name: ____________________________________G#:_____________________

All male U.S. citizens and male aliens residing in the United States born after December 31, 1959, who

are 18 but not yet 26 years old are required to register for the Selective Service with a few exceptions.

Please make sure you are registered if required with the Selective Service System Agency. This form is

Va. Code § 2.2-2804.

in compliance with

If you are required to register for the Selective Service, have you done so?

____ I have registered for Selective Service.

____ I was born on or before the date of December 31, 1959, and am exempt from the

requirement to register for Selective Service.

____ I have been admitted to the United States on a nonimmigrant visa and am exempt from the

requirement to register for Selective Service.

____ I have not registered for Selective Service and have attached documentation from the

Selective Service Agency verifying my exemption.

Signature__________________________________ Date____________________

Revised 10/2011

Selective Service Form