Application For Uniformed Services Identification Card Deers Enrollment

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Please read Privacy Act Statement and Agency Disclosure Notice prior to completing this form.
APPLICATION FOR UNIFORMED SERVICES IDENTIFICATION CARD
MARK HERE FOR GUARD
Form Approved
OR RESERVE PRE-
OMB No. 0704-0020
DEERS ENROLLMENT
ELIGIBILITY
Expires Aug 31, 1999
1. NAME (Last, First, Middle)
2. SEX 3. SSN (or SN)
4. STATUS
5. BR OF SERVICE
11. LAST UPDATE
6. PAY GRADE
7. RANK
8. GEN. CAT
9. TYPE OF CARD ISSUED
10. ID NO.
12. V/I
(YYYYMMMDD)
13. CURRENT RESIDENCE ADDRESS
14. SUPPLEMENTAL ADDRESS INFORMATION
20. HOME TELEPHONE NO.
15. CITY
16. STATE
17. ZIP CODE
18. COUNTRY
19. UIC
(Include Area Code)
21. DATE OF BIRTH
28. MARITAL
22. BLOOD TYPE
23. COLOR EYES
24. COLOR HAIR
25. HEIGHT
26. WEIGHT
27. MEDICARE
STATUS
(YYYYMMMDD)
29. ELIG ST/MC EFF DATE
30. CARD EX/ELIG END DATE
31. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
32. END ELIG REASON
(YYYYMMMDD)
(YYYYMMMDD)
MC
MS
C
MWR
EU
EL
33. NAME (Last, First, Middle)
34. SEX 35. RELATIONSHIP
36. SSN
37. ID NO.
38. LAST UPDATE
39. V/I
40. CURRENT RESIDENCE ADDRESS
41. SUPPLEMENTAL ADDRESS INFORMATION
(YYYYMMMDD)
46. HOME TELEPHONE NO.
47. DATE OF BIRTH
42. CITY
43. STATE
44. ZIP CODE
45. COUNTRY
(Include Area Code)
(YYYYMMMDD)
56. MARITAL STATUS DATE
48. MBI
49. STU
50. INCAP
51. MEDICARE
52. COLOR EYES
53. COLOR HAIR
54. HEIGHT
55. WEIGHT
(YYYYMMMDD)
57. ELIG ST/MC EFF DATE
58. CARD EX/ELIG END DATE
59. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
60. END ELIG REASON
(YYYYMMMDD)
(YYYYMMMDD)
MC
MS
C
MWR
EU
EL
61. NAME (Last, First, Middle)
62. SEX 63. RELATIONSHIP
64. SSN
65. ID NO.
66. LAST UPDATE
67. V/I
68. CURRENT RESIDENCE ADDRESS
69. SUPPLEMENTAL ADDRESS INFORMATION
(YYYYMMMDD)
74. HOME TELEPHONE NO.
75. DATE OF BIRTH
70. CITY
71. STATE
72. ZIP CODE
73. COUNTRY
(Include Area Code)
(YYYYMMMDD)
84. MARITAL STATUS DATE
76. MBI
77. STU
78. INCAP
79. MEDICARE
80. COLOR EYES
81. COLOR HAIR
82. HEIGHT
83. WEIGHT
(YYYYMMMDD)
85. ELIG ST/MC EFF DATE
86. CARD EX/ELIG END DATE
87. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
88. END ELIG REASON
(YYYYMMMDD)
(YYYYMMMDD)
MC
MS
C
MWR
EU
EL
NOTARY SIGNATURE
89. REMARKS (Cite legal documentation, as applicable.)
AND SEAL
I have read and understand the "Conditions Applicable to Sponsor or Applicant" printed in Section VIII. 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 verifying official, the signature must be notarized.)
91. DATE SIGNED
90. SIGNATURE
(YYYYMMMDD)
92. TYPED NAME (Last, First, Middle)
93. PAY GRADE
94. UNIT/COMMAND NAME
95. TITLE
96. UIC
97. DUTY PHONE NO.
98. UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)
100. DATE VERIFIED
99. SIGNATURE
(YYYYMMMDD)
101. TYPED NAME (Last, First, Middle)
102. PAY GRADE
103. UNIT/COMMAND NAME
104. TITLE
105. UIC
106. DUTY PHONE NO.
107. UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)
108. SIGNATURE
109. DATE ISSUED
(YYYYMMMDD)
RECEIPT OF NEW CARD IS ACKNOWLEDGED
111. DATE ISSUED
110. SIGNATURE
(YYYYMMMDD)
DD Form 1172, SEP 96
Previous editions may be used.
USAPA V1.00
This form valid for issue of ID card 90 days from date of verification.

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