2012-2013 Verification of Registration with Selective Service Form
According to Federal Law, a male must register with Selective Service within thirty days of his eighteenth birthday. If you failed to
register with Selective Service you are not eligible to receive any federal financial assistance (i.e. Federal Pell Grant, Federal
Supplemental Education Opportunity Grant, Academic Competitiveness Grant, Federal Work Study, Federal Stafford Loans, etc.)
I understand that decisions regarding eligibility for student financial assistance are made by the Student
Financial Aid Office, not the Selective Service System.
Please complete the form below.
Last Name
First Name
MI
Date of Birth
Address (include apt. #)
City
PGCC ID Number
State
Zip
Phone Number
E-mail Address
Check one box that describes why you did not register with Selective Service.
Attach any documentation to this form that is required:
I am a female - Not required to register.
I am not age 18 or over; my birthdate is: _________
Attach documentation
I was required to register. I knowingly and willfully refused
to register.
I am a male born between 3/29/1957 and 12/31/1957 I was
not required to register.
Attach documentation
I was in the military. Attach copy of DD214.
I am transgendered. Attach copy of birth certificate.
I was INCARCERATED, INSTITUTIONALIZED, HOSPITALIZED,
OR CONFINED TO HOME:
I was a NONCITIZEN/ALIEN: Date you entered the United*
States for the first time: _______________
List dates during which you were (circle appropriate
situation) incarcerated, institutionalized, hospitalized, or
confined to home. For multiple dates, list all.
INS status at time of entry: ______________
________to ________, ________to________,
_______to_______ USCIS Status: _______________
List all alien status(es) held since entering the country.
________to_________ ________to ________,
Attach proof of each instance
_______to_______ USCIS Status: _______________
Attach copies of supporting documentation
If none of these apply to you, attach a typed explanation as to why you did not register for Selective Service
from age 18 to 25.
*The Office of Student Financial Aid assumes that an immigrant or refugee in the required age range who is required to register and
living overseas will be given forms by the Department of State on which the individual certifies that he will register with Selective
Service when he arrives in the United States. Furthermore, it is assumed that immigrants and non-citizens adjusting status within the
United States will be informed by the U.S. Citizenship and Immigration Services, a Bureau of the U.S. Department of Homeland
Security, of the requirement to register [Section 3 of the Military Service Act, 50 U.S.C. App 453(a)]. Unless the student can
demonstrate otherwise, he will be denied eligibility for student financial aid.
Rev. 2/2012
I certify that all information submitted with this form is true and complete to the best of my knowledge. If you
purposely give false or misleading information, you may be fined $20,000, sent to prison, or both.
Signature _________________________________________
Date ____________________
Rev. 2/2012