Form DD Form 1172-2 DD Form 1172-2 Application for Department of Defense Common Access Card

Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.
MARK HERE FOR CIVILIAN
OR CONTRACTOR
PRE-ELIGIBILITY

APPLICATION FOR DEPARTMENT OF DEFENSE COMMON ACCESS CARD
DEERS ENROLLMENT

1. NAME (Last, First, Middle)

6. PAY GRADE

7. GEN. CAT

2. SEX

8. CITIZENSHIP

9. DATE OF BIRTH
(YYYYMMMDD)

13. CURRENT RESIDENCE ADDRESS

3. SSN

OMB No. 0704-0415
OMB approval expires

4. STATUS

5. ORGANIZATION

11. LAST UPDATE
(YYYYMMMDD)

10. PLACE OF BIRTH

12. V/I

14. SUPPLEMENTAL ADDRESS INFORMATION

15. CITY

16. STATE

17. ZIP CODE

20. CITY OF DUTY LOCATION

21. STATE OF DUTY
LOCATION

18. COUNTRY

19. OFFICE E-MAIL ADDRESS

22. COUNTRY OF DUTY
LOCATION

23. ALTERNATIVE E-MAIL ADDRESS

24. SPONSORING OFFICE NAME

25. CONTRACT NUMBER

26. SPONSORING OFFICE ADDRESS (Street, City, State, ZIP Code)

27. SPONSORING OFFICE TELEPHONE NUMBER

28. SUPPLEMENTAL ADDRESS INFORMATION

29. OVERSEAS ASSIGNMENT (Country)

30. OVERSEAS ASSIGNMENT BEGIN DATE
(YYYYMMMDD)

31. OVERSEAS ASSIGNMENT END DATE
(YYYYMMMDD)

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

N E E D S D D 67
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.)
38. DATE SIGNED
(YYYYMMMDD)

37. SIGNATURE

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.
39. TYPED NAME (Last, First, Middle)

41. TITLE

40. UNIT/ORGANIZATION NAME

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

52. DUTY PHONE NO.

53. UNIT/COMMAND ADDRESS (Street, City, State, ZIP Code)

50. TITLE

51. UIC

55. DATE ISSUED
(YYYYMMMDD)

54. SIGNATURE

RECEIPT OF NEW CARD IS ACKNOWLEDGED
57. DATE ISSUED
(YYYYMMMDD)

56. SIGNATURE

DD FORM 1172-2, 20071018 DRAFT

This form valid for issue of Common Access Card for 90 days from date of verification.
PREVIOUS EDITION IS OBSOLETE.

Reset

Adobe Professional 7.0

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 10 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 Directorate, Information Management Division,
1155 Defense Pentagon, Washington, DC 20301-1155 (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.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.
RETURN COMPLETED FORM TO A REAL-TIME AUTOMATED PERSONNEL IDENTIFICATION SYSTEM WORK STATION.

N E E D S D D 67
PRIVACY ACT STATEMENT

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, nonenrollment, refusal of access, and denial of benefits and privileges.]

INSTRUCTIONS

Instructions for the DD Form 1172-2 can be found at:
http://www.dmdc.osd.mil/smartcard/docs/1172-2_Instructions.pdf
DD FORM 1172-2 (BACK), 20071018 DRAFT