Record of Emergency Data (NAVPERS 1070/602)



DEPENDENCY APPLICATION/RECORD OF EMERGENCY DATA1. UNIT ID FORMTEXT 633012. SHIP OR STATION FORMTEXT GEORGIA TECH NROTC UNIT, ATLANTA REGION3. & 4.5. NAME OF SPOUSE FORMTEXT ?????6. DATE OF BIRTH OF SPOUSE FORMTEXT ?????7. RELATIONSHIP FORMTEXT ?????8. PLACE OF MARRIAGE (CITY & STATE OR COUNTRY) FORMTEXT ?????9. DATE MARRIED FORMTEXT ?????10. CITIZENSHIP OF SPOUSE FORMTEXT ?????11. ADDRESS OF SPOUSE FORMTEXT ?????12. DEP FORMTEXT ?????13. NAME OF CHILD OR DEPENDENT FORMTEXT ?????14. DATE OF BIRTH FORMTEXT ?????15. RELATIONSHIP FORMTEXT ?????16. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CHILD FORMTEXT ?????17. DEP FORMTEXT ?????18. NAME OF CHILD OR DEPENDENT FORMTEXT ?????19. DATE OF BIRTH FORMTEXT ?????20. RELATIONSHIP FORMTEXT ?????21. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CHILD FORMTEXT ?????22. DEP FORMTEXT ?????23. NAME OF CHILD OR DEPENDENT FORMTEXT ?????24. DATE OF BIRTH FORMTEXT ?????25. RELATIONSHIP FORMTEXT ?????26. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CHILD FORMTEXT ?????27. DEP FORMTEXT ?????28. NAME OF CHILD OR DEPENDENT FORMTEXT ?????29. DATE OF BIRTH FORMTEXT ?????30. RELATIONSHIP FORMTEXT ?????31. ADDRESS (INCLUDE NAME OF CUSTODIAN IF OTHER THAN CHILD FORMTEXT ?????32. DEP FORMTEXT ?????33. NAME OF FATHER FORMTEXT ?34. ADDRESS OF FATHER (SEE SPECIAL INSTRUCTIONS BEFORE COMPLETING BLOCK 35) FORMTEXT ?????35. DEP FORMDROPDOWN 36. NAME OF MOTHER FORMTEXT ?????37. ADDRESS OF MOTHER (SEE SPECIAL INSTRUCTIONS BEFORE COMPLETING BLOCK 38) FORMTEXT ?????38. DEP FORMDROPDOWN 39. WERE YOU PREVIOUSLY MARRIED? FORMCHECKBOX YES FORMCHECKBOX NO40. PRIOR MARRIAGE DISSOLVED BY FORMCHECKBOX DEATH FORMCHECKBOX ANNULMENT FORMCHECKBOX DIVORCE41. DATE FORMTEXT ?????42 PLACE (CITY & STATE OR COUNTRY) FORMTEXT ?????43. WAS SPOUSE PREVIOUSLY MARRIED? FORMCHECKBOX YES FORMCHECKBOX NO44. PRIOR MARRIAGE DISSOLVED BY FORMCHECKBOX DEATH FORMCHECKBOX ANNULMENT FORMCHECKBOX DIVORCE45. DATE FORMTEXT ?????46 PLACE (CITY & STATE OR COUNTRY) FORMTEXT ?????47. OTHER FORMTEXT N/A48. ADDRESS FORMTEXT ??49. RELATIONSHIP FORMTEXT ?????50. NEXT OF KIN OF SPOUSE (NOT HUSBAND, WIFE, OR MINOR CHILD) FORMTEXT N/A51. ADDRESS FORMTEXT ?????52. RELATIONSHIP FORMTEXT ?????53. BENEFICIARY(S) FOR UNPAID PAY AND ALLOWANCES FORMTEXT ?????54. ADDRESS FORMTEXT ?????55. RELATIONSHIP FORMTEXT ?????56. % FORMTEXT ???57. PERSON TO RECEIVE ALLOTMENT IF IN A MISSING STATUS. SUBJECT TO SECNAV DETERMINATION FORMTEXT ?????58. ADDRESS FORMTEXT ?????59. % FORMTEXT ???60. BENEFICIARY(S) FOR GRATUITY PAY (NO SPOUSE OR CHILD SURVIVING) FORMTEXT ?????61. ADDRESS FORMTEXT ?????62. RELATIONSHIP FORMTEXT ?????63. % FORMTEXT ???64. LIFE INSURANCE DATA (NAME OF CO) (DO NOT INCLUDE SGLI) FORMTEXT ?????65. ADDRESS FORMTEXT ?????66. POLICY NUMBER FORMTEXT ?????67. RELIGION FORMTEXT ?????68.69.70. RANK/RATE FORMTEXT MIDN71. PAGE FORMTEXT 172. OF PAGES FORMTEXT 273. NAME OF DESIGNATOR (LAST, FIRST, MIDDLE) FORMTEXT ?????, FORMTEXT ????? FORMTEXT ?????74. SSN FORMTEXT ??? - FORMTEXT ?? – FORMTEXT ????75. USN 76. USNR FORMCHECKBOX FORMCHECKBOX NAVPERS 1070/602S/N 0106-LF-018-6035PART IIBUREAU OF NAVAL PERSONNELNAVPERS 1070/602 (Rev. 7-72) (PART II) BACK)77. LOCATION OF WILL OR OTHER VALUABLE PAPERS FORMTEXT ????78. REMARKS FORMTEXT ?????Is beneficiary designation of S. G. L. I. on file? FORMCHECKBOX YES FORMCHECKBOX NODATE (If Yes) FORMTEXT ?????NOTE: THIS FORM DOES NOT DESIGNATE OR CHANGE BENEFICIARIES OF GOV’T LIF INSURANCE.79. SIGNATURE OF DESIGNATOR80 SIGNATURE OF APPROVING OFFICER, TITLE, AND DATE FORMTEXT ????? FORMTEXT ?????, FORMTEXT ????? FORMTEXT ?????, FORMTEXT ?????CERTIFICATION OFDESIGNATORI have reviewed the data entered on this form and certify that it is correct.Execute a new NAVPERS 1070/602 if data is not correct.DATESIGNATURE OF DESIGNATORDATESIGNATURE OF DESIGNATOR ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download