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SELECTIVE SERVICE SYSTEM REGISTRATION FORM DO NOT WRITE IN THIS SPACE PRINT ONLY IN BLACK INK AND IN CAPITAL LETTERS ONLY DATE OF BIRTH MM-DD-YYYY SEX Mark with X Male SOCIAL SECURITY ACCOUNT NUMBER Female LAST NAME JR OTHER SUFFIX III FIRST NAME MIDDLE NAME CURRENT MAILING ADDRESS STREET ADDRESS APARTMENT NUMBER CITY STATE TODAY S DATE MM-DD-YYYY ZIP CODE I AFFIRM THE FOREGOING STATEMENTS ARE TRUE SSS FORM 1M JAN 02 SIGNATURE OMB APPROVAL 3240-0002 INT. CUT OFF THIS PORTION BEFORE MAILING*. How To Complete This Form Print Your Information in BLACK INK and in CAPITAL LETTERS ONLY. Block 1. Print your date of birth. Use a two number designation for the month and day and use a four-number designation for the year. Print your full legal name as outlined on the card. Include any suffix in the designated box. Place an X in the correct box. If you have a Social Security Number it is mandatory that you include this information* If you don t have one leave this block blank. Block 5. Print your current mailing address as outlined on the card. Use the two-letter State abbreviation and enter your ZIP code. Block 6. Enter today s date. Use a two-number use a four-number designation for the year. Sign your name in this box. CUT OFF THIS PORTION BEFORE MAILING*. How To Complete This Form Print Your Information in BLACK INK and in CAPITAL LETTERS ONLY. Block 1. Print your date of birth. Use a two number designation for the month and day and use a four-number designation for the year. Block 1. Print your date of birth. Use a two number designation for the month and day and use a four-number designation for the year. Print your full legal name as outlined on the card. Include any suffix in the designated box. Place an X in the correct box. Print your full legal name as outlined on the card. Include any suffix in the designated box. Place an X in the correct box. If you have a Social Security Number it is mandatory that you include this information* If you don t have one leave this block blank. If you have a Social Security Number it is mandatory that you include this information* If you don t have one leave this block blank. Block 5. Print your current mailing address as outlined on the card. Use the two-letter State abbreviation and enter your ZIP code. Block 5. Print your current mailing address as outlined on the card. Use the two-letter State abbreviation and enter your ZIP code. Block 6. Enter today s date. Use a two-number use a four-number designation for the year. Sign your name in this box. CUT OFF THIS PORTION BEFORE MAILING*. How To Complete This Form Print Your Information in BLACK INK and in CAPITAL LETTERS ONLY. Block 1. Print your date of birth. Use a two number designation for the month and day and use a four-number designation for the year. Print your full legal name as outlined on the card. Include any suffix in the designated box. Place an X in the correct box. Block 1. Print your date of birth. Use a two number designation for the month and day and use a four-number designation for the year. Print your full legal name as outlined on the card. Include any suffix in the designated box. Place an X in the correct box. If you have a Social Security Number it is mandatory that you include this information* If you don t have one leave this block blank.

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