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APPLICATION FOR ASSIGNMENT TO HOUSING
1. TYPE SERVICE DESIRED
(X one or both)
a. MILITARY HOUSING
b. HOUSING REFERRAL
(Before completing form, read Privacy Act Statement and instructions on reverse)
SECTION I – APPLICANT INFORMATION
4. EMPLID
5. COAST GUARD COMPONENT
2. NAME OF SPONSOR
3. PAY GRADE
(Last, First, Middle Initial)
6. ADDRESS
7. TELEPHONE NUMBER
8. STATUS OF APPLICANT (X one)
(Street, City, State, Zip Code, Email)
a. CELL
a. MILITARY MEMBER
c. CIVILIAN
b. HOME
b. MILITARY SPOUSE
d. FOREIGN NATIONAL
c. DUTY (DSN)
9. MARITAL STATUS
10. I AM SEPARATED FROM MY DEPENDENTS (x one)
a. VOLUNTARILY
b. INVOLUNTARILY
6a. EMAIL
11. I REQUEST HOUSING FOR
SECTION II – MILITARY CAREER INFORMATION
(X one)
(Civilians skip to item 15 )
a. SELF ONLY
B. SELF AND DEPENDENTS
14. DATES
)
MILITARY APPLICANTS
MILITARY SPOUSE
(Enter in YYMMDD order
12. INSTALLATION/ORGANIZATION TRANSFERRED FROM
a. EFFECTIVE RANK/RATE DATE
b. ACTIVE DUTY SERVICE COMPUTATION
c. TIME REMAINING ON ACTIVE DUTY
13. INSTALLATION/ORGANIZATION TRANSFERRED TO
d. EFFECTIVE CHANGE IN DUTY STATION
e. REPORT DATE
f. ESTIMATED FAMILY ARRIVAL DATE
SECTION III - DEPENDENT DATA
15. DEPENDENTS RESIDING WITH ME
( If more space needed, continue on plain paper)
B. DATE OF BIRTH
a. NAME (Last, First, Middle Initial)
c. SEX
d. RELATIONSHIP
e. REMARKS
(Handicap, health problems, expected additions to family, etc.)
(YYMMDD)
SECTION IV - HOUSING DATA
16. COMMUNITY HOUSING DESIRED
(X as applicable)
a. PURCHASE HOUSE
d. RENT HOUSE
g. RENT MOBILE SPACE
j. ROOM AND BOARD
b. PURCHASE CONDOMINIUM
c. RENT APARTMENT
h. SHARE
k. SUBLET
c. PURCHASE MOBILE HOME
d. RENT MOBILE HOME
i. RENT ROOM
l. TRANSIENT
18. DATE HOUSING NEEDED
19. PRICE RANGE
17. AMENITIES DESIRED
( X as applicable. Write in d. and e.)
(Community Housing)
(YYMMDD)
a. FURNISHED
e. NO. BATHS
b. UNFURNISHED
d. PETS
)
(Allowed
see h, I and j
g. OTHER (Explain)
20. LOCATION PREFERENCE
c. AIR CONDITIONING
(Community Housing)
d. NO. BEDROOMS
PETS
h. NUMBER OF DOGS
i. WEIGHT
j. NUMBER OF CATS
21. REMARKS
22. SIGNATURE OF APPLICANT
23. DATE SUBMITTED
(YYMMDD)
SECTION V - DISPOSITION (To be completed by the Housing Office)
24. MILITARY HOUSING
a.
b. APPLICATION EFFECTIVE (YYMMDD)
c. DD FORM 1747 PROVIDED
d. HOUSING AVAILABILITY (Boxes
APPLICATION RECEIVED
(YYMMDD)
indicated on DD Form 1747)
(YYMMDD and time)
e. APPLICANT PLACED ON WAITING LIST
f. EFFECTIVE PLACEMENT (YYMMDD)
g. BEDROOMS REQUIRED
h. DATE UNIT ASSIGNED (YYMMDD)
SECTION VI – HOUSING REFERRAL CERTIFICATE
On this date I have received a listing of the housing restrictions approved by the
In addition, if any facility refuses to rent or sell to me or I have the reason to believe I
Installation Commander, and I will not reside in any property on the restricted
am being discriminated against, I will promptly notify the Housing Office.
List. I have been brief on (1) the services provided by the Housing Office.
25, SIGNATURE OF APPLICANT
26. DATE SIGNED
(2) the DOD program on equal opportunity for military personnel in Off-base housing,
(YYMMDD)
and (3) nondiscrimination based on physical or mental handicaps.
DD Form 1746, JAN 2010
Modified by 35 CES/CEACH
Previous editions may be used.
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