1.
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Last Name:
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2.
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First Name:
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3.
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Middle Initial:
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4.
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Rank at time of retirement or assignment to the individual ready reserve:
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5.
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1st MOS/AOC:
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6.
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2nd MOS/AOC:
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7.
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3rd MOS/AOC:
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8.
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Phone number: (xxx-xxx-xxxx)
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9.
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Address:
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10.
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City:
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11.
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State:
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12.
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Zip:
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13.
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Email address:
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14.
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Certification (N/A if none):
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15.
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Component:
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16.
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Remarks - Please do not include any Health Insurance Portability and Accountability Act (HIPPA) information or a SSN:
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17.
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Please let us know your status. We do not want to detract from the current care and treatment you are providing to the Nation:
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