Name:
Address:
City: State: Zip:
Branch of service: Grade:
Organization: Date of birth: (mm/dd/yyyy)
Sex: Male Female Marital Status: Married Single Single Parent Dual Military
Status of Sponsor: ACTIVE DUTY MILITARY DoD CIVILIAN NATIONAL GUARD/RESERVE FOREIGN MILITARY RETIRED MILITARY RETIRED DoD CIVILIAN FEDERAL CIVILIAN DoD CONTRACTOR
Phone Numbers: Home: Work: Spouse Work: Emergency: Name of contact:
Email:
Family Members' Information
Spouse Name: Date of Birth: Sex: Male Female
Immediate Family Members (CHILDREN – OLDEST TO YOUNGEST) Name: Date of Birth: Sex: Male Female
Name: Date of Birth: Sex: Male Female