Transcription of APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
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APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
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. CITY OF DUTY LOCATION19. STATE OF DUTY LOCATION20. COUNTRY OF DUTY LOCATION30. OVERSEAS ASSIGNMENT BEGIN DATE (YYYYMMMDD)31. OVERSEAS ASSIGNMENT END DATE (YYYYMMMDD)24. SPONSORING OFFICE NAME26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)25. CONTRACT NUMBER32. ELIGIBILITY EFFECTIVE DATE (YYYYMMMDD)33.
Card and/or non-enrollment in the Defense Enrollment Eligibility Reporting System, refusal to grant access to DoD installations, buildings, facilities, computer systems and networks. Penalty for presenting false claims or making false statements in connection with claims: fine of up to $10,000 or
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