Transcription of APPLICATION FOR IDENTIFICATION CARD/DEERS …
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SECTION VI - RECEIPTSECTION V - DEPENDENT INFORMATION (Attach additional pages if necessary)SECTION III - AUTHORIZED BYSECTION IV - VERIFIED BYSECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKSSECTION I - SPONSOR/EMPLOYEE INFORMATIONAPPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this No. 0704-0415 OMB approval expires Jan 31, 2017 1. NAME (Last, First, Middle)2. GENDER 3. SSN OR DOD ID NO. 4. STATUS5. ORGANIZATION 6. PAY GRADE11. CURRENT HOME ADDRESS12. CITY13. STATE14. ZIP CODE15. COUNTRY16. PRIMARY E-MAIL ADDRESS51. TELEPHONE NUMBER (Include Area Code/DSN)Permission to use for benefits notifications (18 and above)50.
instructions. privacy act statement agency disclosure notice. please do not return your completed form to the above organization. return completed form to a real-time automated personnel identification system work station.
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Application for Identification, Application for Identification Card/DEERS Enrollment, April, Instructions for completion of dd, Application for identification card/deers, RAPIDS Self Service User Guide, Application, Identification, Card, 1172-2, Application for Identification, TRICARE Reserve Select and TRICARE Retired