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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...

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