Selective Service Verification Worksheet (FSELSR) 2016-17
Office of Financial Aid Fax: (904)633-5958 Email: [email protected]
Selective Service Verification Worksheet (FSELSR)
2016-17
Student’s Name: __________________________________________________________________________________________ Last
First
Date of Birth: ______/______/______ Month
Day
Student ID: ______________________
MI
Phone: _______-________________
Year
The Department of Education could not confirm that you are registered with the Selective Service Administration. To receive financial assistance, you must provide documentation to our office that you either are registered or were not required to register with the Selective Service Office. Please read the statements below, select the category that best describes your situation, then complete and sign this form and submit along with the appropriate documentation to FSCJ.
□ □
□
Category A: I am a male U.S. citizen or eligible non-citizen, born after Dec. 31, 1959, who is 18, but not yet 26 years of age. This requirement applies to any person assigned the sex of male at birth. I must register with the Selective Service. I will either provide a copy of my Selective Service Registration Card, a “Status Information Letter” from the Selective Service verifying I am registered, or a printout of my registration from the Selective Service website sss.gov. Category B: I am a male U.S. citizen or eligible non-citizen, 26 years or older, born after December 31, 1959, who has NEVER registered with the Selective Service. You must submit the following documents to FSCJ: • “Status Information Letter” from the Selective Service. To receive a “Status Information Letter” from the Selective Service System, please call 1-847-688-6888. You may also send a written request to the Selective Service System at P.O. Box 94638, Palatine, IL 60094-4638. Ask for a “Status Information Letter”. You can download a request form and its instructions from sss.gov/instructions.html. • A typed and detailed letter of explanation stating why you did not register. Category C: I certify that I am not required to be registered with Selective Service because:
□ □ □ □ □ □ □ □ □
I am a female – submit a copy of your driver’s license or birth certificate. I have not reached my 18th birthday – submit a copy of your driver’s license or birth certificate. I was born before 1960 – submit a copy of your driver’s license or birth certificate. I am in the Armed Services on Active Duty (not a Veteran or in the Reserves) – submit a copy of your current active duty orders and your military ID card. I served on active duty in the U.S. Armed Forces (other than the Reserve Forces, the delayed entry pool or the National Guard) and never registered with the Selective Service and was not dishonorably discharged – submit a Member 4 copy of your DD214. I am a Noncitizen/Citizen who entered the U.S. after I turned 26 – submit a copy of your I-94, I-551, I-551C, or a copy of your citizen certificate, and a brief statement explaining your situation. I am a Noncitizen/Citizen who entered the U.S. as a lawful nonimmigrant and remained in the U.S. under the terms of that visa until after the age of 26 – submit a copy of your I-94, I-551, I-551C, or a copy of your citizen certificate, and a brief statement explaining your situation. I am a resident of the Federated States of Micronesia or the Marshall Islands, or permanent resident of the Trust Territory of the Pacific Islands (Palau) – submit proof of residency status. I was institutionalized or incarcerated for the entire period that I should have registered – provide documentation to verify.
Signature
By signing below, the student acknowledges and confirms that the above is complete and correct. If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Student’s Name: _______________________________
Signature: ____________________________________
Date: ______________
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere. In compliance with Florida State Statute 119.071(5), students should be aware that Florida State College at Jacksonville collects and uses social security numbers (SSNs) if specifically required by law to do so or if necessary for the performance of the College’s duties and responsibilities. The College takes appropriate measures to secure SSNs from unauthorized access and does not release SSNs to other parties except as required to fulfill the College’s duties and responsibilities. (fscj.edu/ssn) Florida State College at Jacksonville does not discriminate against any person on the basis of race, disability, color, ethnicity, national origin, religion, gender, age, sex, sexual orientation/expression, marital status, veteran status, or genetic information in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida 32202 | (904) 632-3221 | [email protected]. Florida State College at Jacksonville is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award the baccalaureate and associate degree. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097, or call (404) 679-4500 for questions about the accreditation of Florida State College at Jacksonville. The Commission is to be contacted only if there is evidence that appears to support an institution’s significant non-compliance with a requirement or standard.
1617 FSELSR
7/21/16
Selective Service Verification Worksheet (FSELSR)
2016-17
Student’s Name: __________________________________________________________________________________________ Last
First
Date of Birth: ______/______/______ Month
Day
Student ID: ______________________
MI
Phone: _______-________________
Year
The Department of Education could not confirm that you are registered with the Selective Service Administration. To receive financial assistance, you must provide documentation to our office that you either are registered or were not required to register with the Selective Service Office. Please read the statements below, select the category that best describes your situation, then complete and sign this form and submit along with the appropriate documentation to FSCJ.
□ □
□
Category A: I am a male U.S. citizen or eligible non-citizen, born after Dec. 31, 1959, who is 18, but not yet 26 years of age. This requirement applies to any person assigned the sex of male at birth. I must register with the Selective Service. I will either provide a copy of my Selective Service Registration Card, a “Status Information Letter” from the Selective Service verifying I am registered, or a printout of my registration from the Selective Service website sss.gov. Category B: I am a male U.S. citizen or eligible non-citizen, 26 years or older, born after December 31, 1959, who has NEVER registered with the Selective Service. You must submit the following documents to FSCJ: • “Status Information Letter” from the Selective Service. To receive a “Status Information Letter” from the Selective Service System, please call 1-847-688-6888. You may also send a written request to the Selective Service System at P.O. Box 94638, Palatine, IL 60094-4638. Ask for a “Status Information Letter”. You can download a request form and its instructions from sss.gov/instructions.html. • A typed and detailed letter of explanation stating why you did not register. Category C: I certify that I am not required to be registered with Selective Service because:
□ □ □ □ □ □ □ □ □
I am a female – submit a copy of your driver’s license or birth certificate. I have not reached my 18th birthday – submit a copy of your driver’s license or birth certificate. I was born before 1960 – submit a copy of your driver’s license or birth certificate. I am in the Armed Services on Active Duty (not a Veteran or in the Reserves) – submit a copy of your current active duty orders and your military ID card. I served on active duty in the U.S. Armed Forces (other than the Reserve Forces, the delayed entry pool or the National Guard) and never registered with the Selective Service and was not dishonorably discharged – submit a Member 4 copy of your DD214. I am a Noncitizen/Citizen who entered the U.S. after I turned 26 – submit a copy of your I-94, I-551, I-551C, or a copy of your citizen certificate, and a brief statement explaining your situation. I am a Noncitizen/Citizen who entered the U.S. as a lawful nonimmigrant and remained in the U.S. under the terms of that visa until after the age of 26 – submit a copy of your I-94, I-551, I-551C, or a copy of your citizen certificate, and a brief statement explaining your situation. I am a resident of the Federated States of Micronesia or the Marshall Islands, or permanent resident of the Trust Territory of the Pacific Islands (Palau) – submit proof of residency status. I was institutionalized or incarcerated for the entire period that I should have registered – provide documentation to verify.
Signature
By signing below, the student acknowledges and confirms that the above is complete and correct. If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Student’s Name: _______________________________
Signature: ____________________________________
Date: ______________
Florida State College at Jacksonville is a member of the Florida College System and is not affiliated with any other public or private university or college in Florida or elsewhere. In compliance with Florida State Statute 119.071(5), students should be aware that Florida State College at Jacksonville collects and uses social security numbers (SSNs) if specifically required by law to do so or if necessary for the performance of the College’s duties and responsibilities. The College takes appropriate measures to secure SSNs from unauthorized access and does not release SSNs to other parties except as required to fulfill the College’s duties and responsibilities. (fscj.edu/ssn) Florida State College at Jacksonville does not discriminate against any person on the basis of race, disability, color, ethnicity, national origin, religion, gender, age, sex, sexual orientation/expression, marital status, veteran status, or genetic information in its programs or activities. Inquiries regarding the non-discrimination policies may be directed to the College’s Equity Officer, 501 West State Street, Jacksonville, Florida 32202 | (904) 632-3221 | [email protected]. Florida State College at Jacksonville is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award the baccalaureate and associate degree. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097, or call (404) 679-4500 for questions about the accreditation of Florida State College at Jacksonville. The Commission is to be contacted only if there is evidence that appears to support an institution’s significant non-compliance with a requirement or standard.
1617 FSELSR
7/21/16
