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MARK HERE FOR CIVILIAN
APPLICATION FOR DEPARTMENT OF DEFENSE COMMON ACCESS CARD
OMB No. 0704-0415
OMB approval expires
Apr 30, 2007
1. NAME (Last, First, Middle)
2. SEX 3. SSN
9. DATE OF BIRTH
11. LAST UPDATE
6. PAY GRADE
7. GEN. CAT
10. PLACE OF BIRTH
13. CURRENT RESIDENCE ADDRESS
14. SUPPLEMENTAL ADDRESS INFORMATION
17. ZIP CODE
19. OFFICE E-MAIL ADDRESS
20. CITY OF DUTY LOCATION
21. STATE OF DUTY
22. COUNTRY OF DUTY
23. ALTERNATIVE E-MAIL ADDRESS
24. SPONSORING OFFICE NAME
25. CONTRACT NUMBER
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
27. SPONSORING OFFICE TELEPHONE NUMBER
29. OVERSEAS ASSIGNMENT (Country)
28. SUPPLEMENTAL ADDRESS INFORMATION
30. OVERSEAS ASSIGNMENT BEGIN DATE
31. OVERSEAS ASSIGNMENT END DATE
32. TYPE OF CARD ISSUED
33. ELIG ST/EFF DATE
34. CARD EXPIRATION DATE
35. SUPPLEMENTAL ASSIGNMENT INFORMATION
Mission Essential Overseas
36. REMARKS (Cite legal documentation, as applicable.)
I have verified the personal identity of the CAC applicant and have verified that a routine
background check has not revealed derogatory information that would pose a security risk to
coalition forces personnel or operation mission.
The individual above is performing in an official capacity on the referenced contract and requires
a CAC in the performance of his/her duties in accordance with contract terms and conditions.
Next of Kin:
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.)
38. DATE SIGNED
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
42. PAY GRADE
43. DUTY PHONE NO.
44. UNIT/ORGANIZATION ADDRESS (Street, City, State, ZIP Code)
46. DATE VERIFIED
47. TYPED NAME (Last, First, Middle)
48. PAY GRADE
49. UNIT/COMMAND NAME
52. DUTY PHONE NO.
53. UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)
55. DATE ISSUED
RECEIPT OF NEW CARD IS ACKNOWLEDGED
57. DATE ISSUED
DD FORM 1172-2, MAY 2004
This form valid for issue of Common Access Card for 90 days from date of verification.
PREVIOUS EDITION IS OBSOLETE.