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CATION STD. 678 (REV. 6/2010) Page 1 PRINT OR TYPE PLEASE SEE INSTRUCTIONS ON BACK PAGE APPLICANT IDENTIFICATION NUMBER (EASY ID) FIRST 3 LETTERS OF MONTH OF BIRTH LAST NAME AT BIRTH EASY ID LAST 4 DIGITS OF SOCIAL SECURITY NUMBER DAY OF BIRTH (M.I.) (First) APPLICANT'S NAME (Last) MAILING ADDRESS (Number) SOCIAL SECURITY NUMBER E-MAIL ADDRESS (Street) (City) (County) WORK TELEPHONE NUMBER (State) (Zip Code) HOME/VRS/TTY TELEPHONE NUMBER EXAMINATION(S) OR JOB TITLE(S) FOR WH.

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