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Dd Form 1172

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Dd Form 1172
Dd Form 1172
Please read Privacy Act Statement and Agency Disclosure Notice prior to completing this form.
DD FORM 1172, SEP 2005
APPLICATION FOR UNIFORMED SERVICES IDENTIFICATION CARD
DEERS ENROLLMENT
PREVIOUS EDITION MAY BE USED.
OMB No. 0704-0020
OMB approval expires
Sep 30, 2008
1. NAME (Last, First, Middle) 2. SEX 3. SSN (or SN) 4. STATUS 5. BR OF SERVICE
6. PAY GRADE 7. RANK 8. GEN. CAT 9. TYPE OF CARD ISSUED 10. ID NO.
11. LAST UPDATE
(YYYYMMMDD)
12. V/I
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
(YYYYMMMDD)
22. BLOOD TYPE 23. COLOR EYES 24. COLOR HAIR 25. HEIGHT 26. WEIGHT 27. MEDICARE
28. MARITAL
STATUS
29. ELIG ST/MC EFF DATE
(YYYYMMMDD)
30. CARD EX/ELIG END DATE
(YYYYMMMDD)
31. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
Medical
Civilian
Medical
Service
Commissary Exchange
Unlimited
Exchange
Limited
Morale, Welfare
& Recreation
32. END ELIG REASON
33. NAME (Last, First, Middle) 34. SEX 35. RELATIONSHIP 36. SSN 37. ID NO.
38. LAST UPDATE
(YYYYMMMDD)
39. V/I 40. CURRENT RESIDENCE ADDRESS 41. SUPPLEMENTAL ADDRESS INFORMATION
42. CITY 43. STATE 44. ZIP CODE 45. COUNTRY
46. HOME TELEPHONE NO.
(Include Area Code)
47. DATE OF BIRTH
(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
(YYYYMMMDD)
58. CARD EX/ELIG END DATE
(YYYYMMMDD)
59. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
Medical
Civilian
Medical
Service
Commissary Exchange
Unlimited
Exchange
Limited
Morale, Welfare
& Recreation
60. END ELIG REASON
61. NAME (Last, First, Middle) 62. SEX 63. RELATIONSHIP 64. SSN 65. ID NO.
66. LAST UPDATE
(YYYYMMMDD)
67. V/I 68. CURRENT RESIDENCE ADDRESS 69. SUPPLEMENTAL ADDRESS INFORMATION
70. CITY 71. STATE 72. ZIP CODE 73. COUNTRY
74. HOME TELEPHONE NO.
(Include Area Code)
75. DATE OF BIRTH
(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
(YYYYMMMDD)
86. CARD EX/ELIG END DATE
(YYYYMMMDD)
87. PRIVILEGES AUTHORIZED (Enter correct abbreviation AFTER privilege)
Medical
Civilian
Medical
Service
Commissary Exchange
Unlimited
Exchange
Limited
Morale, Welfare
& Recreation
88. END ELIG REASON
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)
This form valid for issue of ID card 90 days from date of verification.
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Dd Form 1172
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