Dd Form 1172 - Application For Uniformed Services Identification Card Deers Enrollment
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2Please read Privacy Act Statement and Agency Disclosure Notice prior to completing this form.
MARK HERE FOR GUARD
Form Approved
APPLICATION FOR UNIFORMED SERVICES IDENTIFICATION CARD
OR RESERVE PRE-
OMB No.074-0020
DEERS ENROLLMENT
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Expires Aug 31, 1999
ELIGIBILITY
2. SEX
4. STATUS
5. BR OF SERVICE
1
. NAME (Last, First, Middle)
3. SSN (or SN)
6. PAY GRADE
7. RANK
8. GEN CAT
9. TYPE OF CARD ISSUED
10. ID NO.
11. LAST UPDATE
12. V/I
(YYYYMMMDD)
13. CURRENT RESIDENCE ADDRESS
14. SUPPLEMENTAL ADDRESS INFORMATION
15 CITY
16. STATE
17. ZIP CODE
18. COUNTRY
19. UIC
20. HOME TELEPHONE NO.
(Include Area Code)
21. DATE OF BIRTH
22. BLOOD TYPE
23. COLOR EYES
24. COLOR HAIR
25 HEIGHT
26. WEIGHT
27.
28. MARITAL
MEDICARE
STATUS
(YYYYMMMDD)
29. ELIG ST/MC EFF DATE
30. CARD EX/ELIG END DATE
31. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
32. END ELIG REASON
(YYYYMMMDD)
(YYYYMMMDD)
33. NAME (Last, First, Middle)
34. SEX
35. RELATIONSHIP
36. SSN
37. ID NO.
38. LAST UPDATE
39. V/I
40. CURRENT RESIDENCE ADDRESS
41. SUPPLEMENTAL ADDRESS INFORMATION
(YYYYMMMDD)
42 CITY
43.
44. ZIP CODE
45. COUNTRY
46. HOME TELEPHONE NO.
47. DATE OF BIRTH
STATE
(Include Area Code)
(YYYYMMMDD)
48. MBI
49. STU
50. INCAP
51. MEDICARE
52. COLOR EYES
53. COLOR HAIR
54 HEIGHT
55. WEIGHT
56. MARITAL STATUS DATE
(YYYYMMMDD)
57. ELIG ST/MC EFF DATE
58. CARD EX/ELIG END DATE
59. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
60. END ELIG REASON
(YYYYMMMDD)
(YYYYMMMDD)
61. NAME (Last, First, Middle)
62. SEX
63. RELATIONSHIP
64. SSN
65. ID NO.
66. LAST UPDATE
67. V/I
68. CURRENT RESIDENCE ADDRESS
69. SUPPLEMENTAL ADDRESS INFORMATION
(YYYYMMMDD)
70 CITY
71. STATE
72. ZIP CODE
73. COUNTRY
74. HOME TELEPHONE NO.
75. DATE OF BIRTH
(Include Area Code)
(YYYYMMMDD)
76. MBI
77. STU
78. INCAP
79. MEDICARE
80. COLOR EYES
81. COLOR HAIR
82 HEIGHT
83. WEIGHT
84. MARITAL STATUS DATE
(YYYYMMMDD)
85. ELIG ST/MC EFF DATE
86. CARD EX/ELIG END DATE
87. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
88. END ELIG REASON
(YYYYMMMDD)
(YYYYMMMDD)
89. REMARKS (Cite legal documentation, as applicable.)
NOTARY SIGNATURE
AND SEAL
I have read and understand the “Conditions Applicable to Sponsor or Applicant” printed in Section VIII. 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 verifying official, the signature must be notarized.)
90. SIGNATURE
91. DATE SIGNED
(YYYYMMMDD)
92. TYPED NAME (Last, First, Middle)
93. PAY GRADE
94. UNIT/COMMAND NAME
95. TITLE
96. UIC
97. DUTY PHONE NO.
98. UNIT/COMMAND ADDRESS (Street, City, State, Zip Code)
99. SIGNATURE
100. DATE VERIFIED
(YYYYMMMDD)
101. TYPED NAME (Last, First, Middle)
102. PAY GRADE
103. UNIT/COMMAND NAME
104. TITLE
105. UIC
106. DUTY PHONE NO.
107. UNIT/COMMAND ADDRESS (Street, City, State, Zip Code)
108. SIGNATURE
109. DATE ISSUED
(YYYYMMMDD)
RECEIPT OF NEW CARD IS ACKNOWLEDGED
110. SIGNATURE
111. DATE ISSUED
(YYYYMMMDD)
Previous editions may be used.
Designed by SS Using MS Office 97, Dec 98
DD Form 1172, SEP 96 (EG)
This form valid for issue of ID card 90 days from date of verification..
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