United States Water Patrol

ID/Badge request form


Name:(last____________________ (mid)_____ (first)___________________
DOB:D_____ M______ Y_______ Age:________
Eye Color:_______
Hair Color:__________
Weight:________ Height: ____' ____"
Sex: M____ F_____ 
Blood Type:_____


----------------------- Do not write below this line -------------------------

ID #_______________ Issue Date___________ Expire Date ___________
New___ Reissue____ Replacement____ Active Member_____ Reserve Member
Security Code: _____ Rank:______________ Rate:__________ DOR_________

Station_______________________  Area___________














Uswp-035-04