Form Exchange Form 1100 Exchange Form 1100 Identification & Privilege Card Application

Army & Air Force Exchange Service

IDENTIFICATION & PRIVILEGE CARD APPLICATION
(Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)

OMB NO. 0702-0129
OMB approval expires
DEC 31, 2018

AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, OMB No 0702-0129, is estimated to average
15 minutes 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 the burden estimate or burden reduction suggestions to the Department of
Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. 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 RESPONSE TO THE ABOVE ADDRESS.
Responses should be sent to your local Human Resources Office that provided you the form.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10 U.S.C. §3013; Title 20 U.S.C. §8013, Army Regulation 215-8/AFI 34-211(I), and Executive Order
9397 (SSN).
PRINCIPAL PURPOSES(S): This form collects the information necessary to process your request to obtain privileges as
an authorized patron of the Exchange.
ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD
“Blanket Routine Uses” published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. This
includes disclosure to Federal agencies, and state, local and territorial governments.
DISCLOSURE: Voluntary, however, failure to provide all the requested information may result in the denial of your
application for inadequate data.

INSTRUCTIONS
1.

Print all information in ink. Make sure the information is complete and accurate.

2.

Have your sponsor complete Section I, Section II, the Affidavit for Lost and Stolen Card, and sign and date the
form.

3.

Section III will be completed by an Exchange Human Resource Associate. Do not place any information in this
section.

4.

Complete Section IV, the Dependent Relationship to Sponsor, and Sign and Date under the Dependent
Relationship.

5.

Present the form to the Human Resource associate.

6.

Do not complete section V until directed by the Human Resource associate after you receive your privilege
card.

Exchange Form 1100-016 (AUG 17)

OMB NO. 0702-0129
OMB approval expires
31 December 2018

ARMY & AIR FORCE EXCHANGE SERVICE

IDENTIFICATION & PRIVILEGE CARD APPLICATION
REASON FOR APPLICATION (Check Applicable Box):

NEW ASSOCIATE

DEPENDENT

ID CARD EXPIRED

REPLACE LOST CARD

RETIREE

SECTION I: EMPLOYEE/SPONSOR INFORMATION
LAST NAME

DATE OF BIRTH (YYYYMMMDD)

FIRST NAME

COLOR EYES

COLOR HAIR

HEIGHT

MI

WEIGHT

SOCIAL SECURITY NUMBER (LAST 5)

OFFICE PHONE NO.

SECTION II: ADDITIONAL INFORMATION
REMARKS:

AFFIDAVIT FOR LOST OR STOLEN CARD
STATEMENT REGARDING LOSS AND WHAT YOU HAVE DONE TO RECOVER (I WILL RETURN ANY PREVIOUSLY REPORTED LOST CARDS TO HR IMMEDIATELY):

I CERTIFY THE INFORMATION PROVIDED IN CONNECTION WITH THE ELIGIBILITY REQUIREMENT OF THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
DATE

EMPLOYEE/SPONSOR SIGNATURE

SECTION III: AUTHORIZED BY
I acknowledge that I have verified the above information through the HRIS or by review of applicable documents to support the dependent’s status.
ISSUING OFFICIAL’S NAME (TYPED)

SIGNATURE

CARD NUMBER

ISSUE DATE YYYYMMMDD

EXPIRATION DATE YYYYMMMDD

SECTION IV: DEPENDENT INFORMATION
LAST NAME

DATE OF BIRTH (YYYYMMMDD)

FIRST NAME

COLOR EYES

COLOR HAIR

HEIGHT

GENDER

MI

SOCIAL SECURITY NUMBER

WEIGHT

OTHER MILITARY ID?
YES

NO

DEPENDENT RELATIONSHIP TO SPONSOR
SPOUSE
SPONSORED CHILD
Dependent identified is:
Unmarried full-time student under 23
Dependent on sponsor for over 50% support

UNMARRIED SURVIVING SPOUSE
OTHER—SPECIFY:
Disabled child 21 or over
Unmarried legal ward under 21

DEPENDENT SIGNATURE

DATE

SECTION V: RECEIPT
Receipt of new card is acknowledged
SIGNATURE

EXCHANGE FORM 1100-016 (AUG 17)

UNMARRIED CHILD (under 21)

DATE