DD Form 3225 Community Application to Request Civil-Military Partners

(Updated YYYYMMDD)

COMMUNITY APPLICATION TO REQUEST
CIVIL-MILITARY PARTNERSHIP AND SUPPORT

OMB Control No. 0704-0583
Expires XX/XX/XXXX

The public reporting burden for this collection of information is estimated to average 5.5 hours 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, at [email protected]. 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.

Privacy Advisory
Disclosure of this information is voluntary and will be used to facilitate requests for a civil-military partnership via the Innovative Readiness Program.
When completed, this form contains personally identifiable information and is protected by the Privacy Act of 1974, as amended.
PURPOSE: This form is to be used by civil organizations or non-military government agencies requesting a civil-military partnership via the Innovative
Readiness Program, authorized by 10 U.S.C. § 2012. This form may also be used for similar requests under other authorities. Additional instructions
are on page 6. Requests are contingent on military training needs and DoD resources.
1. REQUEST EXPIRATION DATE
Complete the form below to register and begin your application. Community applications for IRT support are
(YYYY-MM-DD)
due by 30 September each fiscal year. Military applications are due by 1 May each fiscal year. The Military
Services may consider out of cycle requests on a case-by-case basis.
SECTION I — REQUESTING ORGANIZATION INFORMATION
2. NAME OF ENTITY REQUESTING MILITARY SUPPORT (Community, Agency, State, Federal Department, Non-Profit Organization, etc.)

3. HAS THIS ORGANIZATION PREVIOUSLY APPLIED FOR AND RECEIVED SUPPORT AND SERVICES FROM THE
DEPARTMENT OF DEFENSE VIA AN INNOVATIVE READINESS TRAINING OR A CIVIL MILITARY PARTNERSHIP
UNDER OTHER AUTHORITIES?

Yes

No

4a. WHAT TYPE OF ORGANIZATION DO YOU REPRESENT?
4b. IF A NON-PROFIT, WHICH NON-PROFIT ORGANIZATION DO YOU REPRESENT?
5a. STREET ADDRESS OR PO BOX

5b. CITY
5c. STATE
5d. ZIP CODE

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SECTION II — PROJECT OVERVIEW

6. PROJECT NAME

7. TYPE OF PROJECT

Healthcare

Construction

Diving

Transporting Items

Aerial Spray

Cybersecurity

Other

8. BRIEF PROJECT DESCRIPTION (max 700 characters)

SECTION III — PROJECT LOCATION(S)
9. PHYSICAL LOCATION(S) OF PROJECT (continue in item 53 if needed)
Location

Street Address

City

State

5- digit
Zip Code

Congressional
District

#1
#2
#3
#4
#5
#6
10a. DOES SOMEONE OTHER THAN THE REQUESTING ORGANIZATION OWN THE ABOVE REAL ESTATE OR REAL PROPERTY?
No

Yes, the property is titled to:

10b. IF "Yes" SELECTED IN BLOCK 10a, ATTACH PROPERTY AND PERMISSION DOCUMENTATION BELOW. See attachments section at end of application.
11a. ARE THERE ANY RESTRICTIONS, LIMITED EASEMENTS, OR THIRD PARTY PERMISSIONS REQUIRED?
No

Yes (please explain):

11b. IF "Yes" SELECTED IN BLOCK 11a, ATTACH PROPERTY ACCESS DOCUMENTATION BELOW. See attachments section at end of application.
12. WILL THIS ASSISTANCE TAKE PLACE ON A STATE OR FEDERAL MILITARY INSTALLATION (POST, FORT, BASE, OR OTHER FACILITY)
OR ON PROPERTY OPERATED, LEASED, OWNED, OR OCCUPIED BY A FEDERAL OR STATE MILITARY ENTITY?
No
Yes (please explain):

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APPLICATION TO REQUEST FOR INNOVATIVE READINESS TRAINING CIVIL-MILITARY PARTNERSHIP
SECTION IV — PROJECT TIMING
13. PROJECT LENGTH (Estimate the length of time you expect military members to be present)
14. DO YOU HAVE PREFERENCES OR LIMITATIONS ON WHEN THIS ASSISTANCE IS PROVIDED?
Yes (explain details below)
Start Date
End Date
Reason for time
(YYYY-MM-DD)
(YYYY-MM-DD)

No

1st choice
2nd choice
15. DESCRIBE ANY SPECIAL EVENTS, HOLIDAYS, ACTIVITIES, OR LOCAL ISSUES THAT MAY BE ONGOING DURING THE TRAINING.
INCLUDE ANY SITUATIONS THAT THE MILITARY SHOULD BE AWARE OF THAT MAY AFFECT THEIR ACTIVITIES IN THE COMMUNITY.

SECTION V — ADDITIONAL RESOURCES
16. WHAT OTHER FUNDING OR SUPPORT IS YOUR ORGANIZATION CONTRIBUTING FOR THIS PARTNERSHIP?
Amount

Actual or Expected Date
(YYYY-MM-DD)

Funding Type or Source

17a. LIST ANY FACILITIES AVAILABLE AT NO EXPENSE FOR USE BY THE MILITARY DURING THE ASSISTANCE

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17b. I HAVE THE NECESSARY PERMISSION(S) TO USE THE COMMUNITY FACILITIES LISTED IN ITEM 17a.

Yes

No

18. LIST ANY OTHER CONTRIBUTIONS OR RESOURCES THAT YOU OR YOUR NETWORK OF PARTNERS MAY PROVIDE

SECTION VI — PROJECT SIGNIFICANCE
19. DESCRIBE HOW THIS PROJECT CONTRIBUTES TO A LONG-TERM OR BROADER VISION

20. DESCRIBE THE BENEFICIARIES OF THIS PROJECT AND WHEN THEY WILL BEGIN TO BENEFIT

21. DESCRIBE THE LOCAL, REGIONAL, STATE, OR TRIBAL GOVERNMENT SUPPORT FOR THIS PROJECT

22. DESCRIBE THE NETWORK OF PARTNERSHIPS AND STAKEHOLDERS TO BE ENGAGED TO CARRY OUT THIS PROJECT

23. DESCRIBE THE CAPACITY TO SUSTAIN THE TANGIBLE VALUE CREATED BY THIS PROJECT

24. IS THE PROJECT IN AN ECONOMICALLY DISTRESSED AREA?
No
Yes, unemployment rate at least one percentage point above the national unemployment rate during the last 24 months
Yes, per capita income 80 percent or less of the national average per capita income
Yes, other special need:

25. DESCRIBE THE POTENTIAL OF THIS PROJECT TO CREATE POSITIVE CIVIL-MILITARY RELATIONSHIPS

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APPLICATION TO REQUEST FOR INNOVATIVE READINESS TRAINING CIVIL-MILITARY PARTNERSHIP
SECTION VII — MEDICAL PROJECTS ONLY
26. CIVILIAN HEALTH ORGANIZATION SUPERVISOR OVERSEEING THE MEDICAL TRAINING
26a. TITLE

26b. FIRST NAME

26c. LAST NAME

26d. WORK PHONE

26e. EMAIL ADDRESS

27. LIST THE COMMUNITIES WHERE THE TRAINING WILL TAKE PLACE (Community and State are pre-populated from Item 9)
Location

Community or City Name

State

Estimated Patient Load

#1
#2
#3
#4
#5
#6
28. PRIORITIZE THE SERVICES TO BE PROVIDED (1 is the highest priority and 5 is the lowest priority)
Family practice

Dental

Optometry

Behavioral health

Veterinary

Other:

29. PLEASE ATTACH BELOW A DESCRIPTION AND TIMELINES OF HOW YOU WILL COLLECT AND VERIFY THE CREDENTIALS AND
IDENTIFICATION OF MILITARY MEDICAL PROFESSIONALS WHO WILL PROVIDE MEDICAL SERVICES IN THE AREA THE PARTNERSHIP
WILL TAKE PLACE.
SECTION VIII — CONSTRUCTION PROJECTS OR OTHER APPLICABLE PROJECTS

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30. TYPE OF CONSTRUCTION TRAINING (Select all that apply)

Vertical (Structures)

Horizontal (Earthwork)

N/A

Other:

31. SEE ATTACHED BLUE PRINTS, DESIGNS, OR DRAWINGS AT THE END OF APPLICATION
32. SEE ATTACHED LAND USE PERMITS AT THE END OF APPLICATION

33. SEE ATTACHED RIGHT-OF-WAY PERMITS AT THE END OF APPLICATION

SECTION IX — ENVIRONMENTAL COMPLIANCE

34. SEE ATTACHED ENVIRONMENTAL COMPLIANCE DOCUMENTATION AT THE END OF APPLICATION
SECTION X — OTHER NON-PROFIT ORGANIZATIONS NOT LISTED IN 32 USC § 508
35. SEE ATTACHED ORGANIZATION 501(C)3 LETTER FROM THE IRS AT THE END OF APPLICATION
36. SEE ATTACHED ORGANIZATION ARTICLES OF INCORPORATION AT THE END OF APPLICATION
37. SEE ATTACHED ORGANIZATION BY-LAWS AT THE END OF THIS APPLICATION
38. SEE ATTACHED ORGANIZATION IRS FORM 990
SECTION XI — CERTAIN FEDERAL, REGIONAL, STATE, OR LOCAL GOVERNMENT ORGANIZATIONS ONLY
39. ATTACH CHARTER OR FOUNDING LAW AT THE END OF THIS APPLICATION TO CLARIFY ORGANIZATION QUALIFICATION AS A
GOVERNMENT ENTITY
N/A
SECTION XII — INDIAN TRIBAL ENTITIES OR ALASKA NATIVE GOVERNMENTS ONLY
40. MY ENTITY IS LISTED IN THE FEDERAL REGISTRY AS ELIGIBLE TO RECEIVE SERVICES
FROM THE US BUREAU OF INDIAN AFFAIRS.

Yes (Date:

)

No

SECTION XIII — OWNERS AND OPERATORS OF CRITICAL INFRASTRUCTURE
41. The entity is an owner and operator of critical infrastructure recognized by the U.S. Department of Homeland Security (DHS); the U.S.
Cybersecurity and Infrastructure Security Agency (CISA); State or local government, Territory or Tribal Nation government bodies.
Yes

No

41a. What is the entity’s associated Sector Risk Management Agency?

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APPLICATION TO REQUEST FOR INNOVATIVE READINESS TRAINING CIVIL-MILITARY PARTNERSHIP
SECTION XIV — NON-COMPETITION REQUIREMENTS
42. TYPE OF PUBLIC NOTICE:

42a. DATE #1

42b. DATE #2

43. ATTACH COPIES OF THE NON-COMPETITION PUBLIC NOTICES LISTED IN ITEM 42 AT THE END OF THIS APPLICATION
44. ATTACH THE AFFIDAVIT OF PUBLICATION FOR THE PUBLIC NOTICES LISTED IN ITEM 42 AT THE END OF THIS APPLICATION
45. IF THIS IS A CONSTRUCTION REQUEST, I CERTIFY THAT I HAVE LISTED THIS
CONSTRUCTION PROJECT ON THE FEDERAL, STATE, COUNTY, AND/OR CITY
REGISTERS FOR CONSTRUCTION PROJECTS ACCORDING TO FEDERAL, STATE,
COUNTY, AND/OR CITY CONTRACT LAW OR CONTRACT BID PROCESSES.

Yes (Date:

)

No

Yes (explain how they were
adjudicated below)

46. WERE THERE RESPONSES OR INQUIRIES RELATED TO THE NON-COMPETITION
PUBLIC NOTICE REQUIREMENTS?

47. I CERTIFY THAT THIS ASSISTANCE IS NOT REASONABLY AVAILABLE FROM A COMMERCIAL ENTITY OR (IF SO
AVAILABLE), THE COMMERCIAL ENTITY THAT WOULD OTHERWISE PROVIDE SUCH SERVICES HAS AGREED TO
THE PROVISION OF SUCH SERVICES BY THE ARMED FORCES.

No

Yes

No

48. I CERTIFY THAT I HAVE AUTHORITY TO ENTER INTO BINDING AGREEMENTS ON BEHALF OF MY ORGANIZATION.

Yes

No

49. I CERTIFY THAT I HAVE AUTHORITY TO COMMIT RESOURCES OR FUNDS ON BEHALF OF MY ORGANIZATION.

Yes

No

Yes

No

SECTION XV — AGREEMENTS AND CERTIFICATIONS

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50. I AGREE TO THE FOLLOWING RELEASE AND HOLD HARMLESS AGREEMENT:

This request for assistance is subject to the following conditions:
1) Military support will be limited to that which is preapproved by the Department of Defense (DoD).
2) Support is limited to personnel and equipment only.
3) All military personnel and equipment will remain under the control and supervision of the military unit providing the support and services.
I agree on behalf of my organization and its agents, to:
1) Release the DoD, its subordinate units, its officers, military personnel, employees, agents, and servants from any claim, demand, action, liability,
or suit of any nature whatsoever for or on account of any injury, loss, or damage to the requesting organization and its agents arising from or in
any way connected with the military personnel support, excluding, however, any injury, loss, or damage arising solely from the intentional torts or
gross negligence of the military personnel or its agents.
2) Indemnify, defend, and hold harmless the DoD, its subordinate units, officers, military personnel, employees, agents, and servants from any
claim, demand, action, liability, or suit of any nature whatsoever for or on account of any injury, loss, or damage to any third person or third
person’s property arising from or in any way connected with the IRT military support, excluding, however, those arising solely from the intentional
torts or gross negligence of the military personnel or its agents.
With full understanding of the condition and agreements stated above, the undersigned requesting official, who is authorized to execute this
document which is binding on his or her organization and all assigns, heirs, executors, beneficiaries, and derivative claimants, hereby executes this
release of liability and hold harmless agreement.
SECTION XVI — REQUESTING OFFICIAL
51. I am acting on behalf of the sponsoring organization and certify that the information provided above is complete and accurate to the best of my
knowledge. I understand that representatives and personnel from the Military Services volunteer for projects based on military training value.
Service Members may contact me to better understand the requirement, to discuss potential plans, or to inform me of their inability to support this
request. I also understand this request is subject to military training funds availability and that military operational commitments must take priority
and can preclude partnership participation at any time during the process.
51a. TITLE

51b. FIRST NAME

51c. LAST NAME

51d. JOB TITLE
51e. WORK PHONE

51f. CELL PHONE (Optional)

51g. EMAIL ADDRESS
51h. SIGNATURE

51i. DATE (YYYY-MM-DD)

SECTION XVII — ADDITIONAL POINT OF CONTACT INFORMATION (Optional)
52. If you prefer that we contact another person for follow-up correspondence on this request, please designate that person here.
52a. TITLE
52d. WORK PHONE

52b. FIRST NAME

52c. LAST NAME
52e. CELL PHONE

52f. EMAIL ADDRESS

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APPLICATION TO REQUEST FOR INNOVATIVE READINESS TRAINING CIVIL-MILITARY PARTNERSHIP
SECTION XVIII — OTHER (Optional)
53. OTHER (Optional. This block can be used for continuing other blocks or additional details. Attach another sheet if needed.)

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APPLICATION TO REQUEST FOR INNOVATIVE READINESS TRAINING CIVIL-MILITARY PARTNERSHIP
INSTRUCTIONS
Please distribute, complete, sign, and submit this document digitally to the maximum extent
possible.

Item 4a. This helps us determine your eligibility for the program. “Other Federal, Regional,
State, or Local government” should be selected from the dropdown menu if a founding law or
charter would typically need to be cited to clarify your organization’s status as a Federal,
regional, State, or local governmental entity. Examples of these organizations might include
economic development entities, airports, hospitals, and enterprises established by legislative
action.

Item 29. Military medical and health care professionals are not necessarily licensed in the
locale where the IRT support partnership takes place. Pursuant to 10 U.S.C. 1049, military
medical and healthcare professionals may practice the health profession or professions for
which they have an active, unrestricted license at any location in any State, the District of
Columbia, or a Commonwealth, territory, or possession of the United States, regardless of
where they or the patient are located, as long as the practice is within the scope of their
authorized Federal duties. Thus, the requesting organization does not have to apply for further
privileges but must facilitate the verification process by obtaining the relevant military
personnel clinical practice licenses, any relevant clinical certifications, and photo identification
of military health care providers. For more information, see the Joint Commission: https://
www.jointcommission.org/standards/standard-faqs/ambulatory/human-resourceshr/000002242/

Item 4b. Some youth and charitable organizations are specifically listed as eligible in the law
and can be selected here. You may find a list of these organization in 32 U.S.C. §508.

Section VI. This information is required to evaluate the request for military training value and
to determine eligibility for assistance.

Item 5. This is the address for the organization requesting assistance, which may not be the
same as the assistance location.

Section IX. Construction, aerial spray, diving, and sometimes other types of projects must
comply with the National Environmental Policy Act (NEPA); Section 106 of Title 54, USC.; and
all other applicable environmental laws and requirements. Organizations and entities
requesting military assistance serve as the lead agency and must document NEPA
compliance. For more information, contact your local environmental permitting entity and
review the NEPA and Section 106 websites for the most up to date information:
https://www.epa.gov/nepa
https://www.achp.gov/integrating_nepa_106

Item 3. Check “Yes” if your organization has submitted an application in the past AND a
military unit or personnel provided support or services.

Item 9. Add as many locations as needed. Continue in item 51 if more locations are needed
- You may omit the street address for locations that do not have a street address.
- GPS coordinates may be found at: http://www.gps-coordinates.net.* Please specify GPS
coordinates in decimal degree format).
- US Congressional Districts may be found at http://www.house.gov/representatives/find/.*
Item 10. The requesting organization must have clear title to the real estate or real property
where the assistance will take place or provide ownership documentation along with
permission to use the real estate or real property.
Item 11. The requesting organization must demonstrate legal access for the military to provide
the assistance requested in this application.
Item 12. Support and services requested in this application are incidental to military training.
The incidental benefits, outside of military training, should accrue to eligible organizations and
activities outside the DoD. IRT projects, therefore, generally do not take place on a State or
Federal military installation or on property operated, leased, owned or occupied by military
entities. If you check “Yes” in block 12, please provide evidence that 1) the tangible benefit of
the requested assistance clearly accrues to eligible organizations and activities outside the
DoD and 2) the assistance strengthens civil-military relations.

Section X. This information is required to determine the legal eligibility of a non-profit
organization for assistance. These documents are required for all non-profits not listed in the
drop-down menu in item 4b. Organizations in 32 USC §508 do not need to submit these
documents.
Item 35. If the original IRS letter is not available, please request an affirmation letter from the
IRS at: Exempt organizations - Affirmation letters | Internal Revenue Service (irs.gov)
Item 38: 501(C)3 organizations must be in good standing with the IRS to maintain their
exempt status. If an organization does not file as required for three consecutive years, it
automatically loses its tax-exempt status. The IRS Form 990 provides evidence of the
organization’s current standing with the IRS.

NEEDS DD67

Item 13. The amount of time military members will be at the project site may be estimated in
hours, days, weeks, months, or years. This form should not be used for requests that require
less than 100 hours of military assistance.
Item 16. Materials and funding that will be matched with the military assistance should be
listed here. Examples include your organization's internal budget, private donations, grants,
and Federal or State appropriations.

Item 17a. Some facilities might be required to host the assistance, such as a location to host a
medical or dental clinic, a pier or barge to support diving operations, or a loading dock to
facilitate transporting items. Other facilities such as schools, community centers, or places of
worship might be needed and available to support military personnel including lodging, shower
facilities, dining facilities, and fitness facilities.
Item 21. Projects should be coordinated with civilian officials to ensure that the assistance
meets a valid need and does not duplicate other available public services. Projects should be
coordinated with civilian officials to ensure that the assistance meets a valid need and does
not duplicate other available public services. Critical infrastructure projects should be
coordinated with the applicable Federal departments and agencies to ensure that the support
activities are consistent with similar assistance provided under these authorities, including the
authorities of the DHS and CISA, pursuant to the “Homeland Security Act."
Item 22. To the maximum extent practicable, assistance is provided in conjunction with, rather
than separate from, civilian efforts.
Item 24. One measure of economic distress is defined in 13 CFR §301.3(a)(1). You can find
data for your community at http://www.statsamerica.org/.* Other special needs include
substantial out-migration or population loss, underemployment, military base closure or
realignment, defense contractor reductions-in-force, Department of Energy defense-related
funding reductions, natural or other major disasters or emergencies, extraordinary depletion of
natural resources, closing or restructuring of an industrial firm or loss of other major employer,
or negative effects of changing trade patterns.
Item 26. The civilian health organization supervisor is the medical professional responsible for
ensuring all participating local, regional, State, and Federal entities conform to all applicable
local, State, and Federal laws that regulate healthcare delivery within the IRT support activity
State or territory. This supervisor will identify and document responsible individuals to: 1)
handle and dispose of medical waste (a non-military personnel only); 2) comply with the
Clinical Laboratory Improvement Act (CLIA); 3) verify the provided credentials or privileges of
participating military health care providers to include their clinical practice licenses, basic life
support, and if applicable, advance trauma/cardiac certifications with photo ID. (In the event of
conflict on scope of practice or practice standards between military regulation, the State,
locale, or territory where the license originates, and the practice laws of the State, locale, or
territory were the IRT support occurs, the strictest requirement applies); 4) develop an initial
emergency evacuation plan for incidents; 5) develop a follow-up care plan for patient continuity
of care; and 6) plan for handling patients’ records for continuity of care and Privacy Act issues.

Section XI. You only need to provide this information if you selected “Other Federal, regional,
State, or local government” for item 4a. See instructions for item 4a for further explanation.
Section XIII. Owners and operators of Critical Infrastructure (CI) must attest to their
designation as a recognized owner and operator of CI and their associated Sector Risk
Management Agency. The assistance will not include support to elections systems within the
elections infrastructure subsector. The assistance must be coordinated with the applicable
Federal departments and agencies to ensure that the support is consistent with similar
assistance provided under these authorities, including the authorities of the DHS and CISA,
pursuant to the "Homeland Security Act."
Section XIV. This information is required to ensure the assistance does not compete with the
private sector. Public notices must be archivable, accessible, and verifiable. The potential
assistance must be advertised on two separate dates at least 7 days apart, to afford the
community an equitable opportunity to comment. Public notices are typically published in a
public forums such as local newspapers, newspaper or government websites, or town hall
meeting. The advertisements or the forum minutes must be attached to this application along
with their invoices (if applicable). An affidavit shall document that the public notices were
made. Public notices must include sufficient detail of the proposed support activities to
properly inform local commercial entities of the potential impact to their business or services.
The public notices should not contain references to funding availability, though follow-on
conversations to adjudicate public interest may include funding availability. A sample public
notice is posted on the IRT public website. A new public notice advertisement, affidavit, and
any responses to such advertisements, must be submitted along with the community
application and other required documentation for each year of requested IRT support.
Item 45. Additional advertisements to document non-competition may be required by Federal,
State, or local law for construction projects.
Item 46. Please describe the nature of any inquiries related to competition with commercial
entities and how any concerns were resolved.
Item 51h. Signature is enabled when the application is complete. We encourage using
electronic transactions and electronic signatures in accordance with title XVII of Public Law
105-277, commonly known as the “Government Paperwork Elimination Act,” and Public Law
106-229, commonly known as the “Electronic Signatures in Global and National Commerce
Act”.
DEPARTMENT OF DEFENSE INNOVATIVE READINESS TRAINING PROGRAM CONTACT
INFORMATION
Website: http://irt.defense.gov
Mailing address: Innovative Readiness Training
Office of the Assistant Secretary of Defense for Manpower and Reserve
Affairs OASD/M&RA (RI)
1500 Defense Pentagon, Room 2E565
Washington, DC 20301-1500
Email: [email protected]

*Hyperlinks do not constitute DoD endorsement of the web sites or the information, products, or services contained therein.

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