Form Exchange Form 1100 Exchange Form 1100 Army & Air Force Exchange Service Identification & Privi

ARMY & AIR FORCE EXCHANGE SERVICE
IDENTIFICATION & PRIVILEGE CARD APPLICATION
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)

OMB NO. 07020MB approval expires
MMMDD, YYYY

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 15 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, 4800 Mark Center
Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0702-XXXX). 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 RESPONSE TO THE ABOVE ADDRESS.
Responses should be sent to your local Human Resources Office that provided you the form.

PRIVACY ACT STATEMENT
AUTHORITY: Title 10 U.S.C. §3013, "Secretary of the Army"; Title 10 U.S.C. §801 3, "Secretary of the Air Force"; A rmy Regulation 215-3,
"Nonappropriated Funds Personnel Policy"; Army Regulation 215-8/AFI 34-211 (1), "Army and Air Force Exchange Service Operations"; and E.O. 9397
(SSN) as amended.
PRINCIPAL PURPOSES(S): To collect information necessary to process a request to obtain privileges as an authorized patron of the Exchange.
ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD "Blanket Routine Uses"
published at http://dpcld.defense.gov/Privacy/SORNslndex/BianketRoutineUses.aspx. This includes disclosure to Federal agencies, and state, local
and territorial government including to the U.S. Department of Justice/U.S. Attorneys, to the Department of Labor, Departemnt of Veterans Affairs,
Social Security Administration, Federal agencies that have special civilian employee retirement programs; or a national, state, county, municipal, or
other publicly recognized charitable or income security administration agency.
DISCLOSURE: Voluntary, however, failure to provide all the requested information may result in the denial of your application for inadequate data.
A copy of the Privacy Impact Assessment (PIA) for this collection may be located at http://ciog6 army mii/Portals/1/PIA/201 3/EXHRM-TMG pdf

INSTRUCTIONS
1. Print all information in ink. Make sure the information is complete and accurate.
2. Have your sponsor complete Section I, Section II, the Affidavit for Lost and Stolen Card, and sign and date the form.
3. Section Ill will be completed by an Exchange Human Resource Associate. Do not place any information in this section.
4. Complete Section IV, the Dependent Relationship to Sponsor, and Sign and Date under the Dependent Relationship.
5. Present the form to the Human Resource associate.
6. Do not complete Section V until directed by the Human Resource associate after you receive your privilege card.
EXCHANGE FORM 1100-016

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ARMY & AIR FORCE EXCHANGE SERVICE
IDENTIFICATION & PRIVILEGE CARD APPLICATION

OMB

REASON FOR APPLICATION (Check Applicable Box):
D

NEW ASSOCIATE D

DEPENDENT D

ID CARD EXPIRED

D

REPLACE LOST CARD

D

RETIREE

SECTION 1: EMPLOYEE/SPONSOR INFORMATION
lAST NAME

DATE OF BIRTH (YYYYMMMDD)

IMl

FIRST NAME

I

COLOR EYES

I

I

COLOR HAIR

I

WEIGHT

HEIGHT

SOCIAL SECURITY NUMBER (LAST 5)

I

OFFICE PHONE NO.

SECTION II: ADDITIONAL INFORMATION
REMARKS:

AFFIDAVIT FOR LOST OR STOLEN CARD
STATEMENT REGARDING LOSS AND WHAT YOU HAVE DONE TO RECOVER (I WILL RETURN ANY PREVIOUSLY REPORTED LOST CARDS TO HR IMMEDIATELY):

I CERTIFY THE INFORMATION PROVIDED IN CONNECTION WITH THE ELIGIBILITY REQUIREMENT OF THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

I

EMPLOYEE/SPONSOR SIGNATURE

DATE

SECTION Ill: AUTHORIZED BY
I acknowledge that I have verified the above information through the HRIS or by review of applicable documents to support the dependent's status.
SIGNATURE

ISSUING OFFICIAL'S NAME (TYPED)

CARD NUMBER

I

EXPIRATION DATE YYYYMMMDD

'ISSUE DATE YYYYMMMDD

SECTION IV: DEPENDENT INFORMATION

I

LAST NAME

DATE OF BIRTH (YYYYMMMDD)

Ml

FIRST NAME

I

COLOR EYES

I

I

COLOR HAIR

HEIGHT

WEIGHT

ISOCIAL SECURITY NUMBER

I

GENDER

OTHER MILITARY ID?
vEsD

NoD

DEPENDENT RELATIONSHIP TO SPONSOR
D

SPOUSE/SAME SEX DOMESTIC PARTNER

SPONSORED CHILD
D
Dependent identified is:
D

Unmarried full-time student under 23

Dependent on sponsor for over 50% support
D
DEPENDENT SIGNATURE

D

UNMARRIED SURVIVING SPOUSE

D

OTHER-SPECIFY:

D

Disabled child 21 or over
D

Unmarried legal ward under 21

D

UNMARRIED CHILD (under 21)

I

DATE

SECTION V: RECEIPT
Receipt of new card is acknowledged
SIGNATURE

EXCHANGE FORM 1100-016 (DEC 15)

IDATE
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