Dd Form 372 - Request For Verification Of Birth
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11.
DATE OF
REQUEST
Form Approved
(YYYYMMDD)
REQUEST FOR VERIFICATION OF BIRTH
OMB No. 0704-0006
Expires Nov 30, 2004
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0006),
1215 Jefferson Davis Highway, Suite 1204, Arlington, VA
22202-4302.
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any
penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THIS ADDRESS.
RETURN COMPLETED
FORM TO THE ADDRESS LISTED AT THE
BOTTOM OF THE FORM.
SECTION I (Fill in every item in this section)
2. FULL NAME OF CHILD AT TIME OF BIRTH (Last, First, Middle Names)
4.
DATE OF
BIRTH
3.
SEX
(X)
(YYYYMMDD)
MALE
FEMALE
5.
PLACE OF
BIRTH
a. CITY
b.
COUNTY
c. STATE
6.
FULL
NAME OF FATHER (Last, First, Middle Names)
7.
MAIDEN
NAME OF MOTHER (Last, First, Middle Names)
FOLD
8.
PERSON
MAKING REQUEST
FOLD
a. NAME (Last, First, Middle Initial)
b.
RANK/GRADE
c. SIGNATURE
d.
TITLE
SECTION II (For use of vital statistics only)
9.
CORRECTIONS
OF ABOVE STATEMENT MADE ACCORDING TO FACTS ON FILE BY:
a. NAME (Last, First, Middle Initial)
b.
ORGANIZATION
c. ADDRESS
(1) STREET
(2) CITY
(3) STATE
(4) ZIP CODE
10. CERTIFICATE NUMBER 11. FILE DATE (YYYYMMDD)
This is to verify that the above data as corrected are true and correct according
to the record on file in this office.
These
data are confidential and cannot be
used in any manner except for official purposes.
12. VERIFIED BY (Signature)
13. DATE SIGNED
(YYYYMMDD)
DD FORM 372, JAN 2002
PREVIOUS EDITION IS OBSOLETE.
Reset
FOLD TO OUTSIDE
RETURN TO RECRUITER STATION:
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