|
PERSONNEL ACTION
For use of this form, see AR 600-8-6 and DA PAM
600-8-21; the proponent agency is ODCSPER. |
||||||||||||||||||||||||||
DATA
REQUIRED BY THE PRIVACY ACT OF 1974
|
||||||||||||||||||||||||||
|
AUTHORITY: |
Title 5, Section 3012;
Title 10, USC, E.O. 9397. |
|||||||||||||||||||||||||
|
PRINCIPAL PURPOSE: |
Used by soldier in
accordance with DA PAM 600-8-21 when requesting a personnel action on his/her
behalf (Section III). |
|||||||||||||||||||||||||
|
ROUTINE USES: |
To initiate the
processing of a personnel action being requested by the soldier. |
|||||||||||||||||||||||||
|
DISCLOSURE: |
Voluntary. Failure to provide social security number
may result in a delay or error in processing of the request for personnel
action. |
|||||||||||||||||||||||||
|
1. THRU (Include ZIP Code) Battalion Address |
2. TO (Include ZIP
Code) HQDA (TAPC-PDT-P) 200 Stovall Street Alexandria, VA 22332-0478 |
3. FROM (Include
ZIP Code) Company Address |
||||||||||||||||||||||||
SECTION I – PERSONAL
IDENTIFICATION
|
||||||||||||||||||||||||||
|
4. NAME (Last,
First, MI) |
5. GRADE OR RANK/PMOS/AOC |
6. SOCIAL SECURITY
NUMBER |
||||||||||||||||||||||||
|
SECTION II – DUTY STATUS CHANGE (AR 600-8-6) |
||||||||||||||||||||||||||
|
|
7. The above soldier’s duty status has
changed from |
|
|
|||||||||||||||||||||||
|
|
|
to |
|
|||||||||||||||||||||||
|
|
|
effective |
|
hours, |
|
19 |
|
|
||||||||||||||||||
|
|
|
|
|
|
|
|||||||||||||||||||||
|
SECTION III – REQUEST FOR PERSONNEL ACTION |
||||||||||||||||||||||||||
|
8. I request the
following action: |
||||||||||||||||||||||||||
TYPE
OF ACTION
|
PROCEDURE
|
TYPE OF ACTION |
PROCEEDURE |
|||||||||||||||||||||||
|
|
Service School (Enl
only) |
|
|
Reassignment Married
Army Couples |
|
|||||||||||||||||||||
|
|
ROTC or Reserve
Component Duty |
|
|
Reclassification |
|
|||||||||||||||||||||
|
|
Volunteering for
Overseas Service |
|
|
Officer Candidate
School |
|
|||||||||||||||||||||
|
|
Ranger Training |
|
|
Asgmt of Pers with
Exceptional Family Members |
|
|||||||||||||||||||||
|
|
Reassignment Extreme
Family Problems |
|
|
Identification Card |
|
|||||||||||||||||||||
|
|
Exchange Reassignment (Enl
only) |
|
|
Identification Tags |
|
|||||||||||||||||||||
|
|
Airborne Training |
|
|
Separate Rations |
|
|||||||||||||||||||||
|
|
Special Forces
Training/Assignment |
|
|
Leave –
Excess/Advance/Outside CONUS |
|
|||||||||||||||||||||
|
|
On-the-Job Training (Enl
only) |
|
|
Change of Name/SSN/DOB |
|
|||||||||||||||||||||
|
|
Retesting in Army
Personnel Tests |
|
X |
Other (Specify)
Request for Chapter 5-3 |
|
|||||||||||||||||||||
|
9. SIGNATURE OF
SOLDIER (When required) |
10. DATE |
|||||||||||||||||||||||||
|
SECTION IV – REMARKS (Applies to Sections II,
III and V) (Continue on separate sheet) |
||||||||||||||||||||||||||
|
I request voluntary separation UP AR 635-200, Paragraph 5-3, under Secretarial Plenary Authority. The basis for this request is ______________. No other provision in the regulation applies, and early separation is clearly in the best interest of the Army. I request a separation date of ______. 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). 3 Encls 1. Request for Separation 2. Education Counseling 3. ERB/2-1 |
||||||||||||||||||||||||||
SECTION
V – CERTIFICATION/APPROVAL/DISAPPROVAL
|
||||||||||||||||||||||||||
|
11. I certify that the duty status change (Section
II) or that the request for personnel action (Section III) contained
herein – |
||||||||||||||||||||||||||
|
|
p HAS BEEN VERIFIED |
p RECOMMEND
APPROVAL |
p
RECOMMEND DISAPPROVAL |
|||||||||||||||||||||||
|
|
p IS
APPROVED |
p IS
DISAPPROVED |
||||||||||||||||||||||||
|
12.
COMMANDER/AUTHORIZED REPRESENTATIVE |
13. SIGNATURE |
14. DATE |
||||||||||||||||||||||||
DA FORM 4187, OCT 93
|
DA FORM 4187, DEC 82
MAY BE USED |
USAPPC V3.00 COPY 1 |
||||||||||||||||||||||||