Form Exchange Form 1100 Exchange Form 1100 Identification and Privilege Card Application

Army & Air Force Exchange Service

IDENTIFICATION & PRIVILEGE CARD APPLICATION

(Read Aqencv Disclosure Notice, Privacv Act Statement, and Instructions before comf)letinq form.)

0MB NO. 0702-0129
0MB approval expires
XXX XX, 2028

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection ofinformation, 0MB No 0702-0129, 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 ofinformation.
Send comments regarding the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information­
[email protected]. Respondents should be aware that notwithstanding any other provision oflaw, no
person shall be subject to any penalty for failing to comply with a collection ofinformation ifit does not
display a currently valid 0MB control number.

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PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.

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Responses should be sent to your local Human Resources Office that provided you the form.
PRIVACY ACT STATEMENT

AUTHORITY: Title 10 U.S.C. §7013; Title 10 U.S.C. §9013, Army Regulation 215-8/DAFI 34-110(1), and Executive
Order 9397 (SSN).
PRINCIPAL PURPOSES(S): This form collects the information necessary to process your 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/BlanketRoutineUses.aspx. This
includes disclosure to Federal agencies, and state, local and territorial governments.
DISCLOSURE: Voluntary, however, failure to provide all the requested information may result in the denial of your
application for inadequate data.

INSTRUCTIONS

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.

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EXCHANGE FORM 1100-016 (XXX XX)

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