University of Wisconsin-La Crosse
Statement of Selective Service Compliance for Employment
Information on Selective Service registration status must be provided as a condition of
employment in order to comply with Wisconsin law (s. 230.08 (2) (k)). This requirement applies
to all males seeking employment who are 18, but not yet 26 years of ages.
NAME (print)
_______________________________
Last Name
______________________
First Name
___________
Middle Initial
I affirm that the following information is true and correct and I understand that any misstatement,
falsification, or omission may be grounds for refusal to hire, or if hired, termination.
_________________________________________
Signature
__________________
Date (Mo./Day/Yr.)
1.
I certify that I am registered with Selective Service.
2.
I certify that I am NOT required to register with Selective Service because:
I am not 18 through 25 years of age. Enter date of birth__________.
I am a non-immigrant alien lawfully admitted to the United States.
I am a member of the Armed Forces on Activity duty (Note: Those in
the
National Guard and Reservists not on active duty must still register with the
Selective Service)
I am a citizen of Federated States of Micronesia, the Republic of the Marshal
Islands, or the Republic of Palau.
This form must be returned to Human Resources, Graff Hall, Rm. 144 on or before the
start of employment.
For information about Selective Service and on-line registration, go to www.sss.gov
Category
Required to Register?
 MILITARY-RELATED
• Active duty military
• Men attending service academies, like the U.S. Air Force Academy
• Men attending the U.S. Coast Guard Academy
• Men attending the Merchant Marine Academy
• Male students in military officer procurement programs at The Citadel, North
Georgia College & State University, Norwich University, Virginia Military Institute,
Texas A & M University, and Virginia Polytechnic Institute & State University
• Members of the National Guard or Reserves not on active duty
• Delayed Entry Program enlistees
• Men who separate from active duty military for any reason before they turn 26
• Men rejected for enlistment for any reason before turning age 26
 ALIENS **
• Lawful non-immigrants on visas (e.g. diplomatic and consular personnel and
families, foreign students, tourists with unexpired visas (Forms I-94, I-95A), or
those with Border Crossing Documents (Forms I-185, I-186, I-444)
• Permanent resident aliens
• Special (seasonal) agricultural workers (Form I-688)
• Special agricultural workers (Form I-688A)
• Refugee, parolee, and asylee aliens
• Undocumented (illegal) aliens
No *
No *
No *
Yes
No *
Yes
Yes
Yes *
Yes
No
Yes
Yes
No
Yes
Yes
Note: Immigrants who did not enter the United States or maintained their lawful non-immigrant status by
continually remaining on a valid visa until after they were 26 years old were never required to register.
Also, immigrants born before 1960 who did not enter the United States or maintained their lawful nonimmigrant status by continually remaining on a valid visa until after March 29, 1975 were never required
to register.
 CONFINED
• Incarcerated, hospitalized, or institutionalized for medical reasons
No *
 HANDICAPPED PHYSICALLY OR MENTALLY
• Able to function in public with our without assistance
• Continually confined to a residence, hospital, or institution
Yes
No
* Must register within 30 days of release unless already age 26, already registered when released, or
exempt during entire period age 18 through 25 years.
** Residents of Puerto Rico, Guam, Virgin Islands, and Northern Mariana Islands are U.S. citizens.
Citizens of American Samoa are nationals and must register when their permanent address is in the U.S.
This also goes for a national or citizen of the Republic of the Marshall Islands or the Federal States of
Micronesia if they live in the U.S. for more than one year for any reason, except as a student or employee
of the government of his homeland.