Fillable Form Approved: DEERS ENROLLMENT APPLICATION FOR DEPARTMENT OF

Fill Online, Printable, Fillable, Blank Form Approved: DEERS ENROLLMENT APPLICATION FOR DEPARTMENT OF Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form Approved: DEERS ENROLLMENT APPLICATION FOR DEPARTMENT OF

On average this form takes 14 minutes to complete

The Form Approved: DEERS ENROLLMENT APPLICATION FOR DEPARTMENT OF form is 1 page long and contains:

  • 0 signatures
  • 1 check-box
  • 57 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MARK HERE FOR CIVILIAN
OR CONTRACTOR
PRE-ELIGIBILITY
APPLICATION FOR DEPARTMENT OF DEFENSE COMMON ACCESS CARD
DEERS ENROLLMENT
Form Approved
OMB No. 0704-0415
Expires Apr 30, 2007
1. NAME (Last, First, Middle) 2. SEX 3. SSN 4. STATUS 5. ORGANIZATION
6. PAY GRADE 7. GEN. CAT
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. OFFICE E-MAIL ADDRESS
9. DATE OF BIRTH
(YYYYMMMDD)
10. PLACE OF BIRTH
20. CITY OF DUTY LOCATION 21. STATE OF DUTY
LOCATION
22. COUNTRY OF DUTY
LOCATION
23. ALTERNATIVE E-MAIL ADDRESS
30. OVERSEAS ASSIGNMENT BEGIN DATE
(YYYYMMMDD)
31. OVERSEAS ASSIGNMENT END DATE
(YYYYMMMDD)
24. SPONSORING OFFICE NAME
26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)
28. SUPPLEMENTAL ADDRESS INFORMATION
25. CONTRACT NUMBER
32. TYPE OF CARD ISSUED
33. ELIG ST/EFF DATE
(YYYYMMMDD)
34. CARD EXPIRATION DATE
(YYYYMMMDD)
35. SUPPLEMENTAL ASSIGNMENT INFORMATION
36. REMARKS (Cite legal documentation, as applicable.) NOTARY SIGNATURE
AND SEAL
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 authorizing/verifying official, the signature must be notarized.)
37. SIGNATURE
38. DATE SIGNED
(YYYYMMMDD)
39. TYPED NAME (Last, First, Middle) 40. UNIT/ORGANIZATION NAME
41. TITLE 42. PAY GRADE 43. DUTY PHONE NO. 44. UNIT/ORGANIZATION ADDRESS (Street, City, State, ZIP Code)
45. SIGNATURE
46. DATE VERIFIED
(YYYYMMMDD)
47. TYPED NAME (Last, First, Middle) 48. PAY GRADE 49. UNIT/COMMAND NAME
50. TITLE
51. UIC 52. DUTY PHONE NO.
53. UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)
54. SIGNATURE
55. DATE ISSUED
(YYYYMMMDD)
RECEIPT OF NEW CARD IS ACKNOWLEDGED
56. SIGNATURE
57. DATE ISSUED
(YYYYMMMDD)
DD FORM 1172-2, MAY 2004
This form valid for issue of Common Access Card for 90 days from date of verification.
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
29. OVERSEAS ASSIGNMENT (Country)
8. CITIZENSHIP
27. SPONSORING OFFICE TELEPHONE NUMBER
PREVIOUS EDITION IS OBSOLETE.
I certify the individual identified above, based on personal knowledge and available documentation, is in a status eligible for
and requires a CAC in the performance of their duties with the Uniformed Services.
Reset
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL IDENTIFICATION SYSTEM WORK STATION.
AGENCY DISCLOSURE NOTICE
AUTHORITY: 5 U.S.C. Section 301; 10 U.S.C. Sections 1074(c)(1) and 1095(k)(2); 10 U.S.C. chapter 147; 50 U.S.C.
chapter 23; E.O. 9397; E.O. 10450, as amended.
PRINCIPAL PURPOSE(S): To apply for the Common Access Card and/or DEERS Enrollment; control access to and
movement in or on DoD installations, buildings, or facilities; regulate access to DoD computer systems and networks;
and verify eligibility, if authorized, for DoD benefits or privileges. To authenticate the identity of the authorizing/
verifying official for security or auditing purposes.
ROUTINE USE(S): To Federal and State agencies and private entities, as necessary, on matters relating to utilization
review, professional quality assurance, program integrity, civil and criminal litigation, and access to Federal government
and contractor facilities, computer systems, networks, and controlled areas.
DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a Common Access Card;
non-enrollment in the Defense Enrollment Eligibility Reporting System (DEERS); refusal to grant access to DoD
installations, buildings, facilities, computer systems and networks; and denial of DoD benefits and privileges if otherwise
authorized.
[For contractor personnel who
are not required to have a National Agency Check only: Failure to provide a social
security number will not result in denial of the Card, enrollment in DEERS, access to facilities or networks, or if eligible
for, receipt of DoD benefits and privileges (other than non-emergency health care services), provided alternative means
of identification (original birth certificate, passport, etc.) are voluntarily furnished upon request. However, submission of
alternative identification may cause substantial delays; and if not provided, may result in denial of the Card, non-
enrollment, refusal of access, and denial of benefits and privileges.]
DD FORM 1172-2 (BACK), MAY 2004
PRIVACY ACT STATEMENT
INSTRUCTIONS
Instructions for the DD Form 1172-2 can be found at:
http://www.dmdc.osd.mil/smartcard/docs/1172-2_Instructions.pdf
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0415).
Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to
comply with a collection of information if it does not display a currently valid OMB control number.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form Approved: DEERS ENROLLMENT APPLICATION FOR DEPARTMENT OF

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 December 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document