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Dd Form 1172-2

Dd Form 1172-2
Dd Form 1172-2
SECTION V - RECEIPT
SECTION IV - DEPENDENT INFORMATION (Attach additional pages if necessary)
SECTION III - AUTHORIZED BY
SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS
SECTION I - SPONSOR/EMPLOYEE INFORMATION
APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
OMB No. 0704-0415
OMB approval expires
Jan 31, 2014
1. NAME (Last, First, Middle) 2. GENDER 3. SSN OR DOD ID NO. 4. STATUS 5. ORGANIZATION
6. PAY GRADE
11. CURRENT HOME ADDRESS 12. CITY 13. STATE 14. ZIP CODE 15. COUNTRY
16. PRIMARY E-MAIL ADDRESS
9. DATE OF BIRTH
(YYYYMMMDD)
10. PLACE OF BIRTH
18. CITY OF DUTY LOCATION
19. STATE OF DUTY
LOCATION
20. COUNTRY OF
DUTY LOCATION
30. OVERSEAS ASSIGNMENT BEGIN
DATE (YYYYMMMDD)
31. OVERSEAS ASSIGNMENT END
DATE (YYYYMMMDD)
24. SPONSORING OFFICE NAME
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
25. CONTRACT NUMBER
32. ELIGIBILITY EFFECTIVE DATE
(YYYYMMMDD)
33. ELIGIBILITY EXPIRATION DATE
(YYYYMMMDD)
21. REMARKS (Cite legal documentation, as applicable.) NOTARY SIGNATURE
AND SEAL
I certify the information provided in connection with the eligibility requirements of this form is true and accurate to the best of my knowledge.
(If not signed in the presence of the authorizing/verifying official, the signature must be notarized.)
22. SPONSOR/EMPLOYEE SIGNATURE
23. DATE SIGNED (YYYYMMMDD)
34. SPONSORING OFFICIAL NAME (Last, First, Middle)
36. TITLE
37. PAY
GRADE
38. SIGNATURE
64. SIGNATURE 65. DATE ISSUED (YYYYMMMDD)
DD FORM 1172-2, APR 2012
This form valid for issue of DoD ID Card for 90 days from date of verification.
29. OVERSEAS ASSIGNMENT
(Country)
8. CITIZENSHIP
27. SPONSORING OFFICE
TELEPHONE NUMBER
(Include Area Code/DSN)
PREVIOUS EDITION IS OBSOLETE.
I certify the individual identified above, based on personal knowledge and available documentation, is in a status eligible for and requires an
identification card in the performance of their duties with the Uniformed Services.
35. UNIT/ORGANIZATION NAME
39. DATE VERIFIED
(YYYYMMMDD)
40. NAME (Last, First, Middle) 41. GENDER 43. RELATIONSHIP 44. SSN OR DOD ID NO.
45. CURRENT HOME ADDRESS
46. CITY 47. STATE 48. ZIP CODE 49. COUNTRY
Receipt of new card is acknowledged.
7. GEN. CAT
50. ELIGIBILITY EFFECTIVE
DATE (YYYYMMMDD)
51. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)
Adobe Professional 8.0
A
B
17. TELEPHONE NUMBER
(Include Area Code/DSN)
28. OFFICE EMAIL ADDRESS
42. DATE OF BIRTH
(YYYYMMMDD)
52. NAME (Last, First, Middle) 53. GENDER 55. RELATIONSHIP 56. SSN OR DOD ID NO.
57. CURRENT HOME ADDRESS
58. CITY 59. STATE 60. ZIP CODE 61. COUNTRY
62. ELIGIBILITY EFFECTIVE
DATE (YYYYMMMDD)
63. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)
54. DATE OF BIRTH
(YYYYMMMDD)
Dd Form 1172-2
(4.3, 6 Votes)
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