Fillable Form DD 1172-2

What is Form DD 1172-2?

Form DD 1172-2, Application for Identification Card/DEERS Enrollment, is used to apply for and enroll in the Defense Enrollment Eligibility Reporting System (DEERS) for Department of Defense (DOD) benefits and privileges. These benefits include, but are not limited to the following:

• Medical coverage
• DOD identification cards
• Access to DOD installations, buildings, or facilities
• Access to DOD computer systems and networks

How to fill out Form DD 1172-2?

To fill out Form DD 1172-2, one must provide the following information:

Section I. Sponsor or Employee Information

Item 1. Name

Have the employee enter his or her full legal name using the format: Last, First, Middle.

Item 2. Gender

Have the employee enter his or her gender.

Item 3. Social Security Number (SSN) or Department of Defense Identification Number (DOD ID No.)

Have the employee enter his or her Social Security Number (SSN) or Department of Defense Identification Number (DOD ID No.).

Item 4. Status

Have the employee enter his or her marital status.

Item 5. Organization

Have the employee enter his or her organization.

Item 6. Pay Grade

Have the employee enter his or her pay grade.

Item 7. General Category

Have the employee enter the general category he or she is in.

Item 8. Citizenship

Have the employee enter his or her citizenship.

Item 9. Date of Birth

Have the employee enter his or her date of birth using the format: Year-Month-Day.

Item 10. Place of Birth

Have the employee enter his or her place of birth.

Item 11. Current Home Address

Have the employee enter his or her current home address.

Item 12. City

Have the employee enter his or her city.

Item 13. State

Have the employee enter his or her state.

Item 14. ZIP Code

Have the employee enter his or her ZIP code.

Item 15. Country

Have the employee enter his or her country.

Item 16. Primary Email Address

Have the employee enter his or her primary email address.

Have the employee mark the box if he or she is willing to let the Agency use the email address for benefit notifications; otherwise, leave it blank.

Item 17. Telephone Number

Have the employee enter his or her telephone number.

Item 18. City of Duty Location

Have the employee enter the city where his or her duty is located.

Item 19. State of Duty Location

Have the employee enter the state where his or her duty is located.

Item 20. Country of Duty Location

Have the employee enter the country where his or her duty is located.

Section II. Sponsor or Employee Declaration and Remarks

Item 21. Remarks

Have the employee enter any declarations or remarks with citations from legal documentation if it is applicable.

Item 22. Sponsor or Employee Signature

Have the employee affix his or her signature.

By signing this form, the employee certifies that the information provided in connection with the eligibility requirements of this form is true and accurate to the best of his or her knowledge.

Item 23. Date Signed

Have the employee enter the date of signing.

Section III. Authorized By

By filling out this section, the employee certifies that the identified individual, 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 Department of Defense or Uniformed Services.

Item 24. Sponsoring Office Name

Have the employee enter the full legal name of his or her sponsoring office.

Item 25. Contract Number

Have the employee enter the contact number of his or her sponsoring office.

Item 26. Sponsoring Office Address

Have the employee enter the address of his or her sponsoring office.

Item 27. Sponsoring Office Telephone Number

Have the employee enter the telephone number of his or her sponsoring office.

Item 28. Office Email Address

Have the employee enter the official email address of his or her sponsoring office.

Item 29. Overseas Assignment

Have the employee enter his or her overseas assignment.

Item 30. Overseas Assignment Begin Date

Have the employee enter the date when his or her overseas assignment begins.

Item 31. Overseas Assignment End Date

Have the employee enter the date when his or her overseas assignment ends.

Item 32. Eligibility Effective Date

Have the employee enter the eligibility effective date of the office.

Item 33. Eligibility Expiration Date

Have the employee enter the eligibility expiration date of the office.

Item 34. Sponsoring Official Name

Have the employee enter the full legal name of his or her sponsoring official using the format: Last, First, Middle.

Item 35. Unit or Organization Name

Have the employee enter the unit or organization name of his or her sponsoring official.

Item 36. Title

Have the employee enter the title of his or her sponsoring official.

Item 37. Pay Grade

Have the employee enter the pay grade of his or her sponsoring official.

Item 38. Signature

Have the sponsoring official affix his or her signature.

Item 39. Date Verified

Have the employee enter the date of verification using the format: Year-Month-Day.

Section VI. Verified By

Item 40. Verifying Official Name

Have the verifying official enter his or her full legal name using the format: Last, First, Middle Initial.

Item 41. Site Identification

Have the verifying official enter the site identification.

Item 42. Telephone Number

Have the verifying official enter his or her telephone number.

Item 43. Signature

Have the verifying official affix his or her signature.

Section V. Dependent Information

Section A

Item 44. Name

Have the employee enter the full legal name of his or her first dependent using the format: Last, First, Middle.

Item 45. Gender

Have the employee enter the gender of his or her first dependent.

Item 46. Date of Birth

Have the employee enter the date of birth of his or her first dependent.

Item 47. Relationship

Have the employee enter his or her relationship with the first dependent.

Item 48. Social Security Number (SSN) or Department of Defense Identification Number (DOD ID No.)

Have the employee enter the Social Security Number (SSN) or Department of Defense Identification Number (DOD ID No.) of his or her first dependent.

Item 49. Current Home Address

Have the employee enter the current home address of his or her first dependent.

Item 50. Primary Email Address

Have the employee enter the primary email address of his or her first dependent.

Item 51. Telephone Number

Have the employee enter the telephone number of his or her first dependent.

Item 52. City

Have the employee enter the city of his or her first dependent.

Item 53. State

Have the employee enter the state of his or her first dependent.

Item 54. ZIP Code

Have the employee enter the ZIP code of his or her first dependent.

Item 55. Country

Have the employee enter the country of his or her first dependent.

Item 56. Eligibility Effective Date

Have the employee enter the eligibility effective date of his or her first dependent.

Item 57. Eligibility Expiration Date

Have the employee enter the eligibility expiration date of his or her first dependent.

Section B

Item 58. Name

Have the employee enter the full legal name of his or her second dependent using the format: Last, First, Middle.

Item 59. Gender

Have the employee enter the gender of his or her second dependent.

Item 60. Date of Birth

Have the employee enter the date of birth of his or her second dependent.

Item 61. Relationship

Have the employee enter his or her relationship with the second dependent.

Item 62. Social Security Number (SSN) or Department of Defense Identification Number (DOD ID No.)

Have the employee enter the Social Security Number (SSN) or Department of Defense Identification Number (DOD ID No.) of his or her second dependent.

Item 63. Current Home Address

Have the employee enter the current home address of his or her second dependent.

Item 64. Primary Email Address

Have the employee enter the primary email address of his or her second dependent.

Item 65. Telephone Number

Have the employee enter the telephone number of his or her second dependent.

Item 66. City

Have the employee enter the city of his or her second dependent.

Item 67. State

Have the employee enter the state of his or her second dependent.

Item 68. ZIP Code

Have the employee enter the ZIP code of his or her second dependent.

Item 69. Country

Have the employee enter the country of his or her second dependent.

Item 70. Eligibility Effective Date

Have the employee enter the eligibility effective date of his or her second dependent.

Item 71. Eligibility Expiration Date

Have the employee enter the eligibility expiration date of his or her second dependent.

Section VI. Receipt

Item 72. Signature

Have the employee affix his or her signature.

Item 73. Date Issued

Have the employee enter the date of issuing using the format: Year-Month-Day.