Transcription of APPLICATION FOR IDENTIFICATION CARD/DEERS …
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APPLICATION FOR IDENTIFICATION CARD/DEERS …
SECTION V - RECEIPTSECTION IV - DEPENDENT INFORMATION (Attach additional pages if necessary)SECTION III - AUTHORIZED BYSECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKSSECTION I - SPONSOR/EMPLOYEE INFORMATIONAPPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENTP lease read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this No. 0704-0415 OMB approval expiresJan 31, 2014 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 ADDRESS 9. DATE OF BIRTH (YYYYMMMDD)10. PLACE OF BIRTH18.
Title: DD Form 1172-2, Application for Identification Card/DEERS Enrollment, February 2011 Author: WHS/ESD/IMD Created Date: 12/13/2010 3:51:34 PM
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