Application Form – E-Commerce Revolution

Step 1 of 5

Sponsor/Employee Information

First Name

Middle Name

Last Name

Gender

Male

Female

Other

SSN OR DoD ID NO.

Status

Organization

Pay Grade

Gen.Cat

Citizenship

Date of Birth

Place of Birth

Current Address

Street Address Address Line 2 City State ZIP Code

Primary Email Address

Enter Email Confirm Email

Telephone Number

Include Area Code/DSN

City of Duty Location

State of Duty Location

Country of Duty Location

Sponsor/Employee Declaration and Remarks

Remarks

Notary Signature and Seal

Max. file size: 200 MB.

Please confirm

I certify the information provided in connection with the eligibility requirements of this form is true and accurate to the best of my knowledge (If not signed in the presence of the authorizing/verifying official, the signature will be notarized.)

Sponsor/Employee Signature

Max. file size: 200 MB.

Authorized By

Sponsoring Office Name

Contract Number

Sponsoring Office Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sponsoring Office Telephone Number

Office Email Address

Enter Email Confirm Email

Overseas Assignment

Overseas Assignment Begin Date

Overseas Assignment End Date

Eligibility Effective Date

Eligibility Expiration Date

I certify the individual identified above 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 Dod or Uniform Services.

Sponsoring Financial First Name

Sponsoring Financial Middle Name

Sponsoring Financial Last Name

Unit/Organization Name

Title

Pay Grade

Signature

Max. file size: 200 MB.

Date Verified

Verified By

Verifying Official First Name

Verifying Official Middle Name

Verifying Official Last Name

Site Identification

Telephone Number

Signature

Max. file size: 200 MB.

Dependent Information

First Name

Middle Name

Last Name

Gender

Male

Female

Date of Birth

Relationship

SSN OR DOD ID NO.

Current Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Email Address

Enter Email Confirm Email

Telephone Number

Eligibility Effective Date

Eligibility Expiration Date