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MARK HERE FOR CIVILIAN
APPLICATION FOR DEPARTMENT OF DEFENSE COMMON ACCESS CARD
OMB No. 0704-0415
OR CONTRACTOR
OMB approval expires
DEERS ENROLLMENT
PRE-ELIGIBILITY
December 31, 2010
1. NAME (Last, First, Middle)
2. SEX 3. SSN
4. STATUS
5. ORGANIZATION
CONTR
NOAA
9. DATE OF BIRTH
11. LAST UPDATE
6. PAY GRADE
7. GEN. CAT
8. CITIZENSHIP
10. PLACE OF BIRTH
12. V/I
(YYYYMMMDD)
(YYYYMMMDD)
N/A
N/A
N/A
I
13. CURRENT RESIDENCE ADDRESS
14. SUPPLEMENTAL ADDRESS INFORMATION
15. CITY
16. STATE
17. ZIP CODE
18. COUNTRY
19. OFFICE E-MAIL ADDRESS
20. CITY OF DUTY LOCATION
21. STATE OF DUTY
22. COUNTRY OF DUTY
23. ALTERNATIVE E-MAIL ADDRESS
LOCATION
LOCATION
Woods Hole
MA
US
24. SPONSORING OFFICE NAME
25. CONTRACT NUMBER
NOAA Fisheries
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
27. SPONSORING OFFICE TELEPHONE NUMBER
166 Water Street, Woods Hole, MA 02543
(508) 495-2307
28. SUPPLEMENTAL ADDRESS INFORMATION
29. OVERSEAS ASSIGNMENT (Country)
Physical Address: 25 Bernard E. Saint Jean Drive, East Falmouth, MA 02536
N/A
30. OVERSEAS ASSIGNMENT BEGIN DATE
31. OVERSEAS ASSIGNMENT END DATE
32. TYPE OF CARD ISSUED
(YYYYMMMDD)
(YYYYMMMDD)
CAC (DOD Non Uniformed)
N/A
N/A
33. ELIG ST/EFF DATE
34. CARD EXPIRATION DATE
35. SUPPLEMENTAL ASSIGNMENT INFORMATION
(YYYYMMMDD)
(YYYYMMMDD)
N/A
N/A
36. 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.)
37. SIGNATURE
38. DATE SIGNED
(YYYYMMMDD)
I certify the individual identified above, based on personal knowledge and available documentation, is in a status eligible for
and requires a CAC in the performance of their duties with the Uniformed Services.
39. TYPED NAME (Last, First, Middle)
40. UNIT/ORGANIZATION NAME
Romero, Mary Jane
NOAA Fisheries
41. TITLE
42. PAY GRADE
43. DUTY PHONE NO.
44. UNIT/ORGANIZATION ADDRESS (Street, City, State, ZIP Code)
Administrative Assistant
ZS-IV
(508) 495-2307
NOAA Fisheries
46. DATE VERIFIED
45. SIGNATURE
166 Water Street
(YYYYMMMDD)
Woods Hole, MA 02543
47. TYPED NAME (Last, First, Middle)
48. PAY GRADE
49. UNIT/COMMAND NAME
50. TITLE
51. UIC
52. DUTY PHONE NO.
53. UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)
55. DATE ISSUED
54. SIGNATURE
(YYYYMMMDD)
RECEIPT OF NEW CARD IS ACKNOWLEDGED
57. DATE ISSUED
56. SIGNATURE
(YYYYMMMDD)
This form valid for issue of Common Access Card for 90 days from date of verification.
DD FORM 1172-2, DEC 2007
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