Your Name* First MI Last Name of Your Spouse or Father* PrivatePrivate First ClassLance CorporalCorporalSergeantStaff SergeantGunnery SergeantMaster SergeantFirst SergeantMaster Gunnery SergeantSergeant MajorSergeant Major of the Marine CorpsWOCWO2CWO3CWO4CWO52nd Lt1st LtCaptainMajorLt ColonelColonel Rank First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Birthday* MM slash DD slash YYYY Email* Current Status of Spouse* Active Duty Spouse Retired Spouse Veteran Spouse Widowed Spouse Officer Wife Enlisted Wife Civilian Support of the WCDIA Discharge TypeDischarge Date MM slash DD slash YYYY DI School ClassToursFromToWhere Consent* I certify that the information above is true and correct, and that my husband has successfully completed a tour of duty in the MOS of 0911 / 8511, or is currently active as a Drill Instructor in good standing.Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
