Dd Form 1172-2 - Application For Department Of Defense Common Access Card Deers Enrollment
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2Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
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
CONTRACTOR, JOHN E.
M
999-99-9999
CONT
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)
US
1958JAN01
LOS ANGELES, CA
13. CURRENT RESIDENCE ADDRESS
14. SUPPLEMENTAL ADDRESS INFORMATION
12345 NOAA WAY
15. CITY
16. STATE
17. ZIP CODE
18. COUNTRY
19. OFFICE E-MAIL ADDRESS
john.contractor@noaa.gov
SILVER SPRING
MD
20910-0000
USA
20. CITY OF DUTY LOCATION
21. STATE OF DUTY
22. COUNTRY OF DUTY
23. ALTERNATIVE E-MAIL ADDRESS
LOCATION
LOCATION
SILVER SPRING
MD
USA
24. SPONSORING OFFICE NAME
25. CONTRACT NUMBER
987654A
OCAO
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
27. SPONSORING OFFICE TELEPHONE NUMBER
1305 EAST-WEST HIGHWAY, SILVER SPRING, MD 20910
(301) 713-0000
28. SUPPLEMENTAL ADDRESS INFORMATION
29. OVERSEAS ASSIGNMENT (Country)
30. OVERSEAS ASSIGNMENT BEGIN DATE
31. OVERSEAS ASSIGNMENT END DATE
32. TYPE OF CARD ISSUED
(YYYYMMMDD)
(YYYYMMMDD)
33. ELIG ST/EFF DATE
34. CARD EXPIRATION DATE
35. SUPPLEMENTAL ASSIGNMENT INFORMATION
(YYYYMMMDD)
(YYYYMMMDD)
2007MAY01
36. REMARKS (Cite legal documentation, as applicable.)
NOTARY SIGNATURE
AND SEAL
INSERT TRUSTED AGENT INFORMATION
Name
Phone#
Address
CD-591 "Personal Identity Verification (PIV) Request" signed by OSY must be attached to this form
THIS FORM IS SUBMITTED TO THE TRUSTED AGENT NAMED ABOVE WITH A COMPLETED
CD-591. SECTION C OF THE CD-591 MUST BE COMPLETED BY AND CONTAIN THE
SIGNATURE OF AN OFFICE OF SECURITY (OSY) REPRESENTATIVE.
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)
CONTRACTOR'S SIGNATURE
2008JAN31
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
DOE, MARK P (Sponsor, COR or TA)
NOAA/OCAO
41. TITLE
42. PAY GRADE
43. DUTY PHONE NO.
44. UNIT/ORGANIZATION ADDRESS (Street, City, State, ZIP Code)
CHIEF, OCAO
ZA-IV
3017130000
46. DATE VERIFIED
45. SIGNATURE
(YYYYMMMDD)
2008JAN31
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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