State of Arkansas

Statement of Selective Service Status

In Compliance with Act 228

of the 1997 Acts of the Arkansas General Assembly

I understand that to be eligible for enrollment at a public institution of higher learning in the State of Arkansas, I must register, or be exempt from registration, with the Selective Service System in accordance with the Military Selective Service Act, 50 U.S.C. Appx 451 et seq., as specified in Act 228 of the 1997 Acts of the Arkansas General Assembly.

_______ I therefore swear or affirm under penalty of perjury that I have registered with the Selective Service System.

I am exempted from such registration because of the following provisions(s) of the Military Selective Service Act or Act 228 of the 1997 Acts of the Arkansas General Assembly:
______ I am female
______ I am a current member of the armed forces on active duty
______ I am under 18 years of age
______ I am 26 years of age or over
______ I am an exempted resident alien
______ I am a resident of the Federated State of Micronesia, or the Marshall Islands, or a permanent resident of the Trust Territory of the Pacific Islands (Palau)
______ Other, specify:___________________________________________________
________________________________________
Name (Please Print)
__________________________
Social Security Number
_________________________________________
Signature
__________________________
Date

ALL MALES AGE 18 THROUGH 25 MUST SIGN AND RETURN THIS FORM TO THE GRADUATE SCHOOL PRIOR TO REGISTRATION, IN ACCORDANCE WITH STATE LAW.

You must complete, sign, and return this form to this office.
Address:
Arkansas State University
Graduate School
P.O. Box 60
State University, Arkansas 72467