DX-21 Military Census Report - English

2008 Dress Rehearsal
Military Census Report

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

Use a blue or black pen.

Start here
➜ NOTE: Please answer BOTH Question 4 about Hispanic origin and

1. What is your name? Print name below.

Question 5 about race. For this census, Hispanic origins are not races.

Last Name

4. Are you of Hispanic, Latino, or Spanish origin?
First Name

MI

No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican Am., Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin — Print origin, for example,
Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. C

2. What is your sex? Mark I
J
KONE box.
Male

Female

3. What is your age and what is your date of birth?
Please report babies as age 0 when the child is
less than 1 year old.
Age on April 1, 2008

Print numbers in boxes.
Month
Day
Year of birth

5.
What is your race? Mark I
J
Kone or more boxes.
White
Black, African Am., or Negro
American Indian or Alaska Native — Print name of enrolled
or principal tribe. C

Asian Indian
Japanese
Chinese
Korean
Filipino
Vietnamese
Other Asian — Print race, for
example, Hmong, Laotian, Thai,
Pakistani, Cambodian, and so on. C

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander — Print
race, for example, Fijian, Tongan,
and so on. C

Some other race — Print race. C

OMB No. 0607-0919-DR: Approval Expires 8/30/2010

➜ Continue with Question 6 on other side.

Form DX-21 (4-30-2007)

USCENSUSBUREAU
(PID Barcode Place Holder)

DX-21 - Base Black ink

DX-21 - Pantone Green 368 - 10%, 25%, 50% and 100%,

§5’"¤
200601

6. What is the full name and address of the place (Barrack, BOQ,

Military installation or Base name

The Census Bureau estimates that, for the average
respondent, this form will take about 5 minutes to complete,
including the time for reviewing the instructions and answers.
Send comments regarding this burden estimate or any other
aspect of this burden to: Paperwork Reduction Project
0607-0919-DR, U.S. Census Bureau, 4600 Silver Hill Road,
AMSD-3K128, Washington, DC 20233. You may e-mail
comments to Paperwork@census.gov; use "Paperwork
Project 0607-0919-DR" as the subject.

Barrack or dormitory name

Respondents are not required to respond to any
information collection unless it displays a valid approval
number from the Office of Management and Budget.

disciplinary barrack, UPH, etc.) where you are assigned?
Please complete all that apply.

Barrack or dormitory number

House number

Street name

Apartment number
FOR OFFICIAL USE ONLY
City

GQ Control Number

County

State
A. PN

B. JIC1

C. JIC2

ZIP Code

Thank you for completing your official
2008 Dress Rehearsal form.
FORM DX-21 (4-30-2007)

(PID Barcode Place Holder)

DX-21 - Base Black ink

DX-21 - Pantone Green 368 - 10%, 25%, 50%, and 100%

§5’#¤
200602