Dd Form 1172-2 - Application For Department Of Refense Common Access Card Deers Enrollment
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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
Apr 30, 2007
1. NAME (Last, First, Middle)
2. SEX 3. SSN
4. STATUS
5. ORGANIZATION
Contractor
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
13. CURRENT RESIDENCE ADDRESS
14. SUPPLEMENTAL ADDRESS INFORMATION
15. CITY
16. STATE
17. ZIP CODE
18. COUNTRY
19. OFFICE E-MAIL ADDRESS
20. CITY OF DUTY LOCATION
21. STATE OF DUTY
22. COUNTRY OF DUTY
23. ALTERNATIVE E-MAIL ADDRESS
LOCATION
LOCATION
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
K
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)
Mission Essential Overseas
36. REMARKS (Cite legal documentation, as applicable.)
NOTARY SIGNATURE
AND SEAL
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.
Height:
Eye Color:
Next of Kin:
Weight:
Blood Type:
Relationship:
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
37. SIGNATURE
(YYYYMMMDD)
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
41. TITLE
42. PAY GRADE
43. DUTY PHONE NO.
44. UNIT/ORGANIZATION ADDRESS (Street, City, State, ZIP Code)
Contracting
45. SIGNATURE
46. DATE VERIFIED
(YYYYMMMDD)
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)
DD FORM 1172-2, MAY 2004
This form valid for issue of Common Access Card for 90 days from date of verification.
Reset
PREVIOUS EDITION IS OBSOLETE.
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