Dd Form 1172-2 - Application For Identification Card/deers Enrollment
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2OMB No. 0704-0415
APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
OMB approval expires
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
Jan 31, 2014
SECTION I - SPONSOR/EMPLOYEE INFORMATION
1. NAME (Last, First, Middle)
2. GENDER
3. SSN OR DOD ID NO.
4. STATUS
5. ORGANIZATION
9. DATE OF BIRTH
6. PAY GRADE
7. GEN. CAT
8. CITIZENSHIP
10. PLACE OF BIRTH
(YYYYMMMDD)
11. CURRENT HOME ADDRESS
12. CITY
13. STATE 14. ZIP CODE
15. COUNTRY
19. STATE OF DUTY
20. COUNTRY OF
16. PRIMARY E-MAIL ADDRESS
17. TELEPHONE NUMBER
18. CITY OF DUTY LOCATION
LOCATION
DUTY LOCATION
(Include Area Code/DSN)
SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS
NOTARY SIGNATURE
21. REMARKS (Cite legal documentation, as applicable.)
AND SEAL
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.)
23. DATE SIGNED (YYYYMMMDD)
22. SPONSOR/EMPLOYEE SIGNATURE
SECTION III - AUTHORIZED BY
24. SPONSORING OFFICE NAME
25. CONTRACT NUMBER
27. SPONSORING OFFICE
28. OFFICE EMAIL ADDRESS
29. OVERSEAS ASSIGNMENT
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
TELEPHONE NUMBER
(Country)
(Include Area Code/DSN)
30. OVERSEAS ASSIGNMENT BEGIN
31. OVERSEAS ASSIGNMENT END
32. ELIGIBILITY EFFECTIVE DATE
33. ELIGIBILITY EXPIRATION DATE
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
(YYYYMMMDD)
(YYYYMMMDD)
I certify the individual identified above, based on personal knowledge and available documentation, is in a status eligible for and requires an
identification card in the performance of their duties with the Uniformed Services.
34. SPONSORING OFFICIAL NAME (Last, First, Middle)
35. UNIT/ORGANIZATION NAME
36. TITLE
37. PAY
38. SIGNATURE
39. DATE VERIFIED
GRADE
(YYYYMMMDD)
SECTION IV - DEPENDENT INFORMATION
(Attach additional pages if necessary)
A
40. NAME (Last, First, Middle)
41. GENDER
42. DATE OF BIRTH
43. RELATIONSHIP
44. SSN OR DOD ID NO.
(YYYYMMMDD)
45. CURRENT HOME ADDRESS
46. CITY
47. STATE
48. ZIP CODE
49. COUNTRY
50. ELIGIBILITY EFFECTIVE
51. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
52. NAME (Last, First, Middle)
53. GENDER
54. DATE OF BIRTH
55. RELATIONSHIP
56. SSN OR DOD ID NO.
B
(YYYYMMMDD)
57. CURRENT HOME ADDRESS
58. CITY
59. STATE
60. ZIP CODE
61. COUNTRY
62. ELIGIBILITY EFFECTIVE
63. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)
DATE (YYYYMMMDD)
SECTION V - RECEIPT
Receipt of new card is acknowledged.
64. SIGNATURE
65. DATE ISSUED (YYYYMMMDD)
This form valid for issue of DoD ID Card for 90 days from date of verification.
DD FORM 1172-2, FEB 2011
REPLACES PREVIOUS EDITION AND DD FORM 1172, WHICH ARE OBSOLETE.
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