Microsoft Word - Reenlistment Request - CNIC



REENLISTMENT/EXTENTION REQUEST FORMSECTION 1 MEMBER-----SECTION 2 CCC-----SECTION 3 ROUTING MATRIX(MEMBER TO COMPLETE) NAME: L. F., MI, RATE, WARFARESSNPHONE REENLISTMENT DATE/TIME: # YEARS REENLISTING:# MONTHS EXTENDING:SELLING BACK LEAVE:YESNO# of days: Home of Record:CITEZENSHIP: LOCATION OF RE-UP (CONUS/OCONUS): _______ REENLISTING OFFICER: LOCATION AND TIME OF REENLISTMENT: UNIFORM: NAME(L,F, MI), RANK, TITLE Do you request spousal/children Certificate(s) of List the full name(s) and relationship(s) Appreceation? to be printed on certificates YES NO MEDICAL/DENTAL DEPARTMENT PERSONNEL ONLY (COMPLETE THIS PORTION FIRST BEFORE ROUTING)MEDICAL SCREENING:SNM () IS() IS NOT MEDICALLY APPROVED FOR REENLISTMENT (SIGNATURE AND DATE)(N/A FOR EXT)DENTAL SCREENING:SNM () IS() IS NOT ELIGIBLE FOR REENLISTMENT (SIGNATURE AND DATE) (N/A FOR EXT)I CERTIFY THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.I WILL IMMEDIATELY INFORM MY COMMAND CAREER COUNSELOR IF THERE ARE ANY CHANGES.MEMBER SIGNATURE: SRB ELIG:(COMMAND CAREER COUNSELOR TO COMPLETE)YESNORATE/NEC:SRB AWARD LEVEL SRB ZONE: ADSD:EAOS: YYMMDDEXTENSION: (As applicable)MONTHS OFPRD:EXTENSIONPTS APPROVAL:Pg. 13ContractDischarge/Reenlistment Cert.SRB submittedCCC: SIGN/DATEEmail: (ROUTING MATRIX)Y / N LPO Sign/Date Y / N LCPO Sign/DateY / N CMC Sign/Date Y / N XO Sign/Date Y / N CO Sign/DateALL REQUESTS MUST BE RETURNED TO CCC’S OFFICE NLT 30 WORKING DAYS PRIOR TO DESIRED REENLISTMENT DATE. FOR ALL SRB ELIGIBLE MEMBERS REQUEST MUST BE RETURNED BY 45 DAYS.Privacy Act, 1974 as amended applies. This document contains information which must be protected IAW DoD 5400.11R and isFor Official Use Only ................
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