PERSONNEL ACTION
For use of this form, see AR 600-8-6 and DA PAM
600-8-21; the proponent agency is ODCSPER. |
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DATA
REQUIRED BY THE PRIVACY ACT OF 1974
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AUTHORITY: |
Title 5, Section 3012;
Title 10, USC, E.O. 9397. |
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PRINCIPAL PURPOSE: |
Used by soldier in accordance
with DA PAM 600-8-21 when requesting a personnel action on his/her behalf (Section
III). |
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ROUTINE USES: |
To initiate the
processing of a personnel action being requested by the soldier. |
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DISCLOSURE: |
Voluntary. Failure to provide social security number
may result in a delay or error in processing of the request for personnel
action. |
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1. THRU (Include ZIP Code) Battalion Address |
2. TO (Include ZIP
Code) Brigade Address |
3. FROM (Include
ZIP Code) Company Address |
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SECTION I – PERSONAL
IDENTIFICATION
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4. NAME (Last,
First, MI) |
5. GRADE OR
RANK/PMOS/AOC |
6. SOCIAL SECURITY
NUMBER |
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SECTION II – DUTY STATUS CHANGE (AR 600-8-6) |
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7. The above soldier’s duty status has
changed from |
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to |
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effective |
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hours, |
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19 |
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SECTION III – REQUEST FOR PERSONNEL ACTION |
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8. I request the
following action: |
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TYPE
OF ACTION
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PROCEDURE
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TYPE OF ACTION |
PROCEEDURE |
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Service School (Enl
only) |
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Reassignment Married
Army Couples |
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ROTC or Reserve
Component Duty |
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Reclassification |
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Volunteering for Overseas
Service |
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Officer Candidate
School |
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Ranger Training |
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Asgmt of Pers with
Exceptional Family Members |
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Reassignment Extreme
Family Problems |
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Identification Card |
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Exchange Reassignment (Enl
only) |
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Identification Tags |
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Airborne Training |
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Separate Rations |
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Special Forces
Training/Assignment |
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Leave – Excess/Advance/Outside
CONUS |
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On-the-Job Training (Enl
only) |
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Change of Name/SSN/DOB |
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Retesting in Army
Personnel Tests |
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X |
Other (Specify)
Request for Chapter 8 (Pregancy) |
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9. SIGNATURE OF
SOLDIER (When required) |
10. DATE |
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SECTION IV – REMARKS (Applies to Sections II,
III and V) (Continue on separate sheet) |
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I request voluntary separation UP AR 635-200, Chapter 8, for pregnancy. I request a separation date of _____. However, I understand that the separation authority and my military physician will determine the separation date. I further understand that the separation date must not be later than 30 days before expected date of delivery, or the latest date my military physician will authorize me to travel, whichever is earlier. I understand that if I have not completed my statutory service obligation (10 USC 651), I may be transferred to the Individual Ready Reserve (IRR). 5 Encls 1. Request for Separation 5. ERB/2-1 2. Stmt by/on behalf of Dependent 3. Stmt by ______ 4. Stmt by ______ |
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SECTION
V – CERTIFICATION/APPROVAL/DISAPPROVAL
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11. I certify that the duty status change (Section
II) or that the request for personnel action (Section III) contained
herein – |
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p HAS BEEN VERIFIED |
p
RECOMMEND APPROVAL |
p
RECOMMEND DISAPPROVAL |
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p IS
APPROVED |
p IS
DISAPPROVED |
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12.
COMMANDER/AUTHORIZED REPRESENTATIVE |
13. SIGNATURE |
14. DATE |
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DA FORM 4187, OCT 93
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DA FORM 4187, DEC 82
MAY BE USED |
USAPPC V3.00 COPY 1 |
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