Transcription of APPLICATION FOR IDENTIFICATION CARD/DEERS …
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APPLICATION FOR IDENTIFICATION CARD/DEERS …
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. PRIMARY E-MAIL ADDRESSP ermission to use for benefits notifications (18 and above)64. PRIMARY E-MAIL ADDRESS65. TELEPHONE NUMBER (Include Area Code/DSN)Permission to use for benefits notifications 9.
Title: DD Form 1172-2, Application for Identification Card/DEERS Enrollment, January 2014 Author: WHS/ESD/IMD Created Date: 1/15/2014 3:36:27 PM
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