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1. CONTROL NUMBER
REQUEST AND AUTHORITY FOR LEAVE
This form is subject to the Privacy Act of 1974. For use of this form, see AR 600-8-10.
The proponent agency is DCS, G-1. (See instructions on reverse.)
PART I
3. SSN (For security purposes, Requestor or Soldier, 4. RANK
is advised to leave the SSN field blank, as (S1) can
input your SSN information last.)
SPC
2. NAME (Last, First, Middle Initial)
Kelley, Christopherlee G
6. LEAVE ADDRESS (Street, City, State, ZIP Code and
Phone No.)
288A fishwheel ave, jber, ak 99505
325-212-2261
9.
a. ACCRUED
7. TYPE OF LEAVE
ORDINARY
37
9
NA
109th Transportation, JBER
907-384-9536
OTHER
d. EXCESS
10.
a. FROM
DATES
b. TO
20160225
NA
12. SUPERVISOR RECOMMENDATION/SIGNATURE
11. SIGNATURE OF REQUESTOR
Requestor: You must complete block 2 and blocks
APPROVAL
DISAPPROVAL
4 through blocks 10a., to activate and sign this
Supervisor: Requestor must digitally sign block 11 to allow you to
digital signature. Block 3 SSN, can remain blank.
complete block 12 (check either Approval or Disapproval). Once block 12
Digitally signed by
KELLEY.CHRIST KELLEY.CHRISTOPHER
is checked, this will allow you to activate and sign this digital signature.
OPHERLEE.GUT LEE.GUTIE.1409074673
2016.02.18
IE.1409074673 Date:
20:50:13 -09'00'
20160225
8. ORGN, STATION, AND PHONE NO.
EMERGENCY
PERMISSIVE TDY
NUMBER DAYS LEAVE
b. REQUESTED
c. ADVANCED
5. DATE
20160304
13. SIGNATURE AND TITLE OF
APPROVING AUTHORITY
Approving Authority: Supervisor must digitally
sign block 12 activating and allowing you to sign
this digital signature.
20160218
14.
a. DATE
b. TIME
DEPARTURE
c. NAME/TITLE/SIGNATURE OF DEPARTURE AUTHORITY
15.
a. NUMBER DAYS
b. DATE APPROVED
EXTENSION
c. NAME/TITLE/SIGNATURE OF APPROVAL AUTHORITY
16.
a. DATE
b. TIME
RETURN
c. NAME/TITLE/SIGNATURE OF RETURN AUTHORITY
17. REMARKS
Chargeable...