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

OMB No. 0704-0415
OMB approval expires

APPLICATION FOR IDENTIFICATION CARD/DEERS ENROLLMENT
Please read Agency Disclosure Notice, Privacy Act Statement, and Instructions prior to completing this form.

SECTION I - SPONSOR/EMPLOYEE INFORMATION
1. NAME (Last, First, Middle)

6. PAY GRADE

7. GEN. CAT

2. GENDER

3. SSN OR DOD ID NO.

4. STATUS

9. DATE OF BIRTH
(YYYYMMMDD)

8. CITIZENSHIP

11. CURRENT HOME ADDRESS

10. PLACE OF BIRTH

12. CITY

13. STATE

17. TELEPHONE NUMBER 18. CITY OF DUTY LOCATION
(Include Area Code/DSN)

16. PRIMARY E-MAIL ADDRESS

5. ORGANIZATION

14. ZIP CODE

15. COUNTRY

19. STATE OF DUTY
LOCATION

20. COUNTRY OF
DUTY LOCATION

SECTION II - SPONSOR/EMPLOYEE DECLARATION AND REMARKS
NOTARY SIGNATURE
AND SEAL

21. REMARKS (Cite legal documentation, as applicable.)

D R A F T
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.)
23. DATE SIGNED (YYYYMMMDD)

22. SPONSOR/EMPLOYEE SIGNATURE

SECTION III - AUTHORIZED BY
24. SPONSORING OFFICE NAME

25. CONTRACT NUMBER

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

30. OVERSEAS ASSIGNMENT BEGIN
DATE (YYYYMMMDD)

27. SPONSORING OFFICE
TELEPHONE NUMBER
(Include Area Code/DSN)

31. OVERSEAS ASSIGNMENT END
DATE (YYYYMMMDD)

28. OFFICE EMAIL ADDRESS

32. ELIGIBILITY EFFECTIVE DATE
(YYYYMMMDD)

29. OVERSEAS ASSIGNMENT
(Country)

33. ELIGIBILITY EXPIRATION DATE
(YYYYMMMDD)

I certify the individual identified above, based on personal knowledge and available documentation, is in a status eligible for and requires an
identification card in the performance of their duties with the Uniformed Services.
34. SPONSORING OFFICIAL NAME (Last, First, Middle)

35. UNIT/ORGANIZATION NAME

37. PAY
GRADE

36. TITLE

38. SIGNATURE

39. DATE VERIFIED
(YYYYMMMDD)

SECTION IV - DEPENDENT INFORMATION (Attach additional pages if necessary)
A

40. NAME (Last, First, Middle)

41. GENDER

42. DATE OF BIRTH
(YYYYMMMDD)

43. RELATIONSHIP

44. SSN OR DOD ID NO.

45. CURRENT HOME ADDRESS

46. CITY

B

47. STATE

52. NAME (Last, First, Middle)

48. ZIP CODE

53. GENDER

49. COUNTRY

54. DATE OF BIRTH
(YYYYMMMDD)

50. ELIGIBILITY EFFECTIVE
DATE (YYYYMMMDD)

55. RELATIONSHIP

51. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)

56. SSN OR DOD ID NO.

57. CURRENT HOME ADDRESS

58. CITY

59. STATE

60. ZIP CODE

61. COUNTRY

62. ELIGIBILITY EFFECTIVE
DATE (YYYYMMMDD)

63. ELIGIBILITY EXPIRATION
DATE (YYYYMMMDD)

SECTION V - RECEIPT
Receipt of new card is acknowledged.
64. SIGNATURE

DD FORM 1172-2, 20101214 DRAFT

65. DATE ISSUED (YYYYMMMDD)

This form valid for issue of DoD ID Card for 90 days from date of verification.
Adobe Professional 8.0
REPLACES PREVIOUS EDITION AND DD FORM 1172, WHICH ARE OBSOLETE.

Reset

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, Washington
Headquarters Services, 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.

D R A F T
PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. Section 301; 10 U.S.C. chapter 147; 10 U.S.C. Sections 1061 - 1065, 1072 - 1074, 1074a - 1074c,
1074c(1), 1076, 1076a, 1077, 1095(k)(2); 50 U.S.C. chapter 23; E.O. 9397; E.O. 10450, as amended.
PRINCIPAL PURPOSE(S): To apply for and enroll in the Defense Enrollment Eligibility Reporting System (DEERS) for DoD
benefits and privileges. These benefits and privileges include, but are not limited to, medical coverage, DoD Identification
Cards, access to DoD installations, buildings or facilities, and access to DoD computer systems and networks.
ROUTINE USE(S): To Federal and State agencies and private entities; individual providers of care, and others, on matters
relating to claim adjudication, program abuse, utilization review; professional quality assurance; medical peer review, program
integrity, third party liability, coordination of benefits and civil and criminal litigation, and access to Federal government and
contractor facilities, computer systems, networks, and controlled areas. The DD Form 1172-2 currently covers the RUs that
would include retirees and dependents. To the Department of Health and Human Services, the Department of Veterans
Affairs, the Social Security Administration, and to other Federal, state, and local government agencies to identify individuals
having benefit eligibility in another plan or program. For a complete list of DEERS routine uses, visit:
http://privacy.defense.gov/notices/osd/DMDC02.shtml.
Applicant information is subject to computer matching within the Department of Defense or with other Federal or non-Federal
agencies. Matching programs are conducted to assure that an individual eligible under a Federal program is not improperly
receiving duplicate benefits from another program. A beneficiary or former beneficiary who has applied for privileges of a
Federal Benefit Program and has received concurrent assistance under another plan will be subject to adjustment or recovery
of any improper payments made or delinquent debts owed.
DISCLOSURE: Voluntary; however, failure to provide information may result in denial of a Uniformed Services Identification
Card and/or non-emrollment 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
imprisonment for up to five years or both.

INSTRUCTIONS

The instructions for completing the DD Form 1172-2 should be closely followed to ensure accurate data collection and to
preclude overcollection of information. Section IV of this form should only be completed if benefits or sponsorship is being
requested for/by an eligible sponsor or their dependent. Instructions for the DD Form 1172-2 can be found at:
http://www.cac.mil/assets/pdfs/DD_1172-2_Instructions.pdf

DD FORM 1172-2 (BACK), 20101214 DRAFT