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SSS FORM 404 (FEBRUARY 2011) PREVIOUS EDITIONS ARE OBSOLETE. STOCK WILL BE DESTROYED OMB Approval # 3240-0005 SSS Board Member Application Completing the attached information sheet does not obligate you to accept an appointment nor does it constitute an offer of an appointment. Each individual selected for recommendation will be contacted to determine availability. This application is the first step in identifying individuals who are willing to serve as SSS Board Members. A. Eligibility Requirements: In order to be considered for appointment on a Board, 1. You MUST: a. be a citizen of the United States; b. be at least 18 years of age; c. reside in the county in which the Board has jurisdiction; d. be able to devote sufficient time to accomplish Board Member duties; e. be willing to apply the SSS law and Regulations fairly and uniformly; and f. be registered with the SSS, if required to do so. 2. You MAY NOT: a. be an active or retired member of the Armed Forces or any Reserve Component; b. have 20 or more cumulative years of prior SSS Board Membership; c. be employed by public or private enterprise which handles SSS matters; d. be a member of a law enforcement occupation as defined by SSS policy (example: police officer or judge); e. be a SSS employee or a spouse of: i. a compensated or uncompensated employee of the SSS; ii. a Reserve Officer assigned to the SSS; or iii. an appointee to any other SSS Board. f. have been convicted, forfeited collateral, or are now under changes for a criminal offense, other than a traffic offense with only a fine of $400.00 or less; except if a conviction is older than 10 years it was for a misdemeanor, and the person has since displayed outstanding integrity in the community. B. Appointment: Local Board Members are appointed by the Director after recommendation by the Governor of their State. District Appeal Board Members are appointed by the Director upon recommendation of a Region Director. Each SSS Board is composed of 5 members and membership of each Board should, to the maximum extent possible, be proportionately representative of the race and national origin of the registrants within its jurisdiction. No citizen will be denied membership based on gender. C. Selection: Individuals are selected by a process which begins with preliminary screening to determine where the basic eligibility requirements are met. Personal interviews will be conducted with those persons found eligible. A prospective Board Member’s indication o f willingness to serve by filling out the attached form is not a guarantee of a recommendation or a final commitment to serve. Each nominee w ill sign an Oath of Office and Waiver of Pay and receive written confirmation of appointment before serving as a Board Member. D. Training: Each Board Member may receive approx imately 5 hours initial training in members’ duties and responsibilities, as well as continuation training consisting of 2 hours, which may be scheduled yearly. Board Members training may also be kept current by various mailings. If Board Members are unable to attend 3 consecutively scheduled training sessions, they will be asked to resign or will be removed from their positions. E. Responsibilities: Board Members are responsible for keeping abreast of changing regulations and procedures by attending training and meeting as a Board as scheduled, as often as necessary, to consider and decide on Registrants’ claim(s) for deferment, exemption and postponement of induction. Decisions of Local Boards are subject to appeal. Because Board Members are key to the success of the SSS, they are asked to attend all training sessions and Board meetings. F. Remuneration: Board Members receive no pay for serving on the Board. They are, however, reimbursed for authorized travel expenses incurred while conducting SSS Duties. This includes travel to required training sessions and to Board meetings. Remuneration will occur via Direct Deposit. Boar d Members do receive satisfaction knowing that they have had vital role in insuring that our nation’s defense manpower needs have been met in a just and impartial manner. G. 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. Locate your state abbreviation; this will designate the Region Headquarters address. REGION I REGION II REGION III CT, DE, DC, IL, IN, ME, MA, MD, MI, AL, AR, FL, GA, KY, LA, MS, NC, PR, SC, TN, AK, AZ, CA, CO, GU, HI, IA, ID, KS, MO, MN, NH, NJ, NY, OH, PA, RI, VT, or WI TX, VI, VA, or WV MP, MT, NE, ND, NM, NV, OK, OR, SD, UT Building 3400, Suite 276 2400 Lake Park Drive, Suite 270 WA, or WY North Chicago, IL 60064-9983 GA 30080 Stapleton Building, Suite 1014 3401 Quebec Street Denver, CO 80207-2323 Page 1 Personnel Policies and Procedures Manual - Chapter 520 The Selective Service System (SSS) is seeking applicants to serve as uncompensated members of the SSS Boards. There is no plan to begin inducting young men into military service 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 we select and train citizens who would be willing to serve if needed. ---PAGE BREAK--- SSS FORM 404 (FEBRUARY 2011) PREVIOUS EDITIONS ARE OBSOLETE. STOCK WILL BE DESTROYED OMB Approval # 3240-0005 SPECIFIC INSTRUCTIONS FOR SSS FORM 404 (Self explanatory items are not mentioned below) Item 1. Social Security Number: Use 9 digits. Item 2. Title: Enter a one digit number 1=Mr., 2= Mrs., 3= Ms., 4= Miss., 5 = Dr., 6= Other Suffix: Example: Jr., Sr., I, II, III Item 3. Residence: Address (location) where you reside. Enter Number, Street, Route, Apt. Number, city, county, state. ZIP: Fill in all 9 numbers. Item 4. Mailing: If address is the same as residence, write “SAME”. Item 5. Residence-Business Phones/e-mail/Fax: Enter phones followed by your primary e-mail and fax 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 check one or more boxes as appropriate on the application form. Item 10: Armed Forces Status: Enter a one digit number from the list below: 1 = Non Applicable 3 = Active National Guard/Reserve 5 = Retired 6 = Honorable discharge, not 7 = Other than honorable, not retired 2 = Active Duty 4 = Inactive Reserve retired 8 = Type of discharge unknown Item 17. Former Board Member: If you have served as a Board Member before, fill in the location and dates of service. If you have additional previous tours of service use the continuation sheet. Item 19. Males Only: If you are male and required to register, enter your Selective Service Number. Item 20. Occupation: Enter a two - digit number code from the list below. You may enter further information in the space provided. If you choose “Other – 99”, enter your occupation in the space provided at Item 20. 01 = Accounting 07 = Legal 12 = Real Estate 18 = Engineering 02 = Banking 08 = Homemaker 13 = Retired 19 = Computer/Data Processing 03 = Education 09 = Manufacturing 14 = Sales 20 = Retail 04 = Agriculture 10 = Medical/Dental 15 = Self Employed 05 = Government 11 = Secretary/Clerical 16 = Trades 99 = Other (Specify) 06 = Insurance 17 = Student Item 21. Occupational Category: Enter a two-digit number code from the list below. You may enter further information in the space provided. If you enter numbers 23, 24, or 25, enter a description in the space provided in item 21. 01 = Asst. Attorney General 11 = District Attorney 21 = Sheriff 02 = Asst. District Attorney 12 = District Judge 22 = State Attorney 03 = Attorney General 13 = Justice of the Peace 23 = Judicial (Specify) 04 = Bail Commissioner 14 = Magistrate 24 = Penal (Specify) 05 = Circuit Court Judge 15 = Mayor (w/Judicial Duties) 25 = Law Enforcement (Specify) 06 = Court Attorney 16 = Police Court Judge 26 = Other 07 = County Judge 17 = Police Justice 08 = Court Warrant Officer 18 = Police Officer 99 = None of the Above 09 = Court Bailiff 19 = Parole/Probation Officer 10 = Deputy Sheriff 20 = Prosecuting Attorney Item 22. Civic/Professional Organizations: If you belong to any civic/professional organizations enter name of Organization and office held. Use the Continuation sheet as needed. PRIVACY ACT STATEMENT THE INFORMATION REQUESTED ON THIS F ORM IS UNDE R AUTHORITY OF SECTION 10(b)(3) OF THE MILITARY SELECTIVE SERVICE ACT ( 50 U.S.C APP 460 FURNISHING THE INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE THE REQUESTED INFORMATION WILL PRECLUDE SELECTION FOR APPOINTMENT. INFORMATION SUPPLIED O N THIS FORM WILL BE USED IN SELECTING AND APPOINTING MEMBERS OF THE LOCAL BOARDS AND DISTRICT APPEAL BOARDS OF THE SELECTIVE SERVICE S YSTEM. 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. Page 2 ---PAGE BREAK--- SSS FORM 404 (FEBRUARY 2011) PREVIOUS EDITIONS ARE OBSOLETE. STOCK WILL BE DESTROYED OMB Approval # 3240-0005 Selective Service System Potential Board Member Information See Instructions and Privacy Statement (Page 2) 1. Social Security Number: 2. Title: Last Name: Suffix: First Name: MI: 3. Residence Address: (Enter Number, Street, Route, Apt., number where you reside. Please no P.O Box) City: County: State: Zip: (9 Digit Zip Requested) 4. Mailing Address: City: State: Zip: Employer: 5. Residence Phone: 6. Business Phone: Extension: E-mail: 7. Birth Date: Month/Day/Year 8a. Ethnicity: Do you consider yourself to be Hispanic or Latino? Please check one box only: YES NO 8b. Race: What is your race? Please check one or more boxes as appropriate: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 9. Sex: Male Female 10. Are you a member of the Armed Forces of the United States? Enter Number: (See Instructions – Page 2) YES NO (For Items 11 through 19 check ‘yes’ or ‘no’) 11. Are you a citizen of the United States? 12. Are you a compensated employee of the Selective Service System? 13. Are you a spouse of an employee of Selective Service, as defined in the Eligibility Requirements on Page 1, paragraph A.2.e? 14. Are you (or are you the spouse of) a Reserve Force Officer with Selective Service, or an appointee to another Selective Service board? 15. Will you attend required board meetings and training sessions? 16. Do you feel you would be objective and unbiased in performing the duties as a member of a Selective Service Board? 17. Are you a former Selective Service Board Member? (Use continuation sheet if necessary) If yes: Board No: City: Start Date: State: County: Stop Date: "For Official Use Only - Privacy Sensitive: Any misuse or unauthorized disclosure may result in both civil and criminal penalties" "For Official Use Only - Privacy Sensitive: Any misuse or unauthorized disclosure may result in both civil and criminal penalties" Enter a one digit number ---PAGE BREAK--- SSS FORM 404 (FEBRUARY 2011) PREVIOUS EDITIONS ARE OBSOLETE. STOCK WILL BE DESTROYED OMB Approval # 3240-0005 18. Have you ever been convicted, forfeited collateral, or are now under charges for a criminal offense, other than traffic offense with only a fine of $400.00 or less? If yes, explain below. 19. Males only: I certify that I am in compliance with the registration requirement of the Military Selective Service Act. If no, explain below. Selective Service Number: 20. Occupation: (See Instruction, Page 2) 21. Occupation Category: (See Instructions Page 2) Description: 22. I belong to the following civic/professional organizations: (If additional space is needed, use continuation sheet). Organization Office Held (if any) I certify that all of 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 We estimate 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 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. ---PAGE BREAK--- SSS FORM 404 (FEBRUARY 2011) PREVIOUS EDITIONS ARE OBSOLETE. STOCK WILL BE DESTROYED OMB Approval # 3240-0005 Selective Service System OATH OF OFFICE AND WAIVER OF PAY (Required of every person who undertakes to render voluntary uncompensated service in the administration of the Military Selective Service Act) OATH OF OFFICE I do solemnly swear (or affirm) that if appointed to any position 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 I hereby expressly declare that I am volunteering my services to assist in the administration of the Military Service Act, and if appointed to an uncompensated position, I hereby expressly waive any right to pay or compensation in any form whatsoever for services heretofore or hereafter rendered. This waiver is signed by me pursuant to the provisions of the Selective Service Regulations. Printed or Typed Full Name Signature Date AUTHENTICATION SUBSCRIBED AND SWORN (or affirmed) BEFORE ME ON THIS DAY OF Printed or Typed Full Name and Title of Individual Authorized to Administer Oath Signature INSTRUCTIONS Completing this portion of the Form 404 will not commit you to accept an appointment nor does it constitute and offer of appointment. Oath of Office and Waiver of Pay – To be completed and signed by the prospective applicant when completing the interview and the first portion of this form. Authentication – To be completed and signed by the person so authorized in Chapter 520, PPPM, after the prospective applicant has signed the Oath of Office and Waiver of Pay. This form will be retained in the Board Member’s file. ---PAGE BREAK--- 18. Additional former Selective Service Board member: 23. Additional civic/professional organizations: Organization Office Held (if any) Potential Board Member Information Continuation Sheet SELECTIVE SERVICE SYSTEM Board No: City: Start Date: State: County: Stop Date: Board No: City: Start Date: State: County: Stop Date: Board No: City: Start Date: State: County: Stop Date: