SPECIAL REQUEST/AUTHORIZATION
SPECIAL REQUEST/AUTHORIZATION
PRIVACY ACT STATEMENT THE AUTHORITY TO REQUEST THIS INFORMATION IS CONTAINED IN 5 USC 301. THE PRINCIPLE PURPOSE OF THE INFORMATION IS TO ENABLE YOU TO MAKE KNOWN YOUR DESIRE FOR ITEMS LISTED OR FOR SOME OTHER SPECIAL CONSIDERATION OR AUTHORIZATION. THE INFORMATION WILL BE USED TO ASSIST OFFICIALS AND EMPLOYEES OF THE DEPARTMENT OF THE NAVY IN DETERMINING YOUR ELIGIBILITY FOR AND APPROVING OR DISAPPROVING THE SPECIAL CONSIDERATION OR AUTHORIZATION BEING REQUESTED. COMPLETION OF THE FORM IS MANDATORY, FAILURE TO PROVIDE REQUIRED INFORMATION MAY RESULT IN DELAY IN RESPONSE TO OR DISAPPROVAL OF YOUR REQUEST.
1. NAME:
2. RATE:
3. SHIP OR STATION:
4. DATE OF REQUEST: (YYYYMMDD)
5. DEPARTMENT/DIVISION:
6. DUTY SECTION/GROUP:
7. NATURE OF REQUEST: 8. NO. OF DAYS REQUESTED: 9. DISTANCE (MILES): 10. LEAVE ADDRESS:
LEAVE
SPECIAL LIBERTY
FROM (DATE AND TIME):
SPECIAL PAY
COMMUTED RATIONS
TO (DATE AND TIME):
OTHER (BELOW)
MODE OF TRAVEL:
CAR
AIR
TRAIN
BUS
11. TELEPHONE NUMBER:
12. REASON FOR REQUEST:
R/R to attend Navy Trauma Training Center Class XXXXX from DDMM YY to DDMMMYY. My deployment date is: DDMMYY Deploying to: ________ with _______. Approval implies verification of deployment information by Chain of Command.
13. SIGNATURE OF APPLICANT: (Use CAC for digital signature)
14. I am eligible and obligate myself to perform all duties of person making application.
SIGNATURE OF STANDBY:
15. RECOMMENDED APPROVAL
RANK/RATE/TITLE:
SIGNATURE:
YES
NO
16. RECOMMENDED APPROVAL
YES
NO
RANK/RATE/TITLE:
SIGNATURE:
17. RECOMMENDED APPROVAL
RANK/RATE/TITLE:
SIGNATURE:
YES
NO
18. RECOMMENDED APPROVAL
RANK/RATE/TITLE:
SIGNATURE:
YES
NO
19. RECOMMENDED APPROVAL
RANK/RATE/TITLE:
SIGNATURE:
YES
NO
20. RECOMMENDED APPROVAL
RANK/RATE/TITLE:
SIGNATURE:
YES
NO
21.
SIGNATURE:
APPROVED
DISAPPROVED
22. REASON FOR DISAPPROVAL:
DUTY STATION: DATE: DATE: DATE: DATE: DATE: DATE:
NAVPERS 1336/3 (Rev. 10-2011)
FOR OFFICIAL USE ONLY - PRIVACY SENSITIVE
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