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:
3. SHIP OR STATION:
5. DEPARTMENT/DIVISION:
2. RATE:
4.DATE OF REQUEST: (YYYYMMDD)
6.DUTY SECTION/GROUP:
7. NATURE OF REQUEST: |
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LEAVE |
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SPECIAL |
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SPECIAL PAY |
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COMMUTED |
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OTHER |
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LIBERTY |
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RATIONS |
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(BELOW) |
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8. |
NO. OF DAYS REQUESTED: |
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FROM (DATE AND TIME): |
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TO (DATE AND TIME): |
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9. |
DISTANCE (MILES): |
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MODE OF TRAVEL: |
CAR |
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AIR |
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TRAIN |
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BUS |
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10. LEAVE ADDRESS: |
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11. TELEPHONE NUMBER: |
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12.REASON FOR REQUEST:
13.SIGNATURE OF APPLICANT: (Use CAC for digital signature)
14. I am eligible and obligate myself to |
SIGNATURE OF STANDBY: |
DUTY STATION: |
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perform all duties of person making |
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application. |
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15. |
RECOMMENDED APPROVAL |
RANK/RATE/TITLE: |
SIGNATURE: |
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DATE: |
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YES |
NO |
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16. |
RECOMMENDED APPROVAL |
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RANK/RATE/TITLE: |
SIGNATURE: |
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DATE: |
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YES |
NO |
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17. |
RECOMMENDED APPROVAL |
RANK/RATE/TITLE: |
SIGNATURE: |
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DATE: |
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YES |
NO |
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18. |
RECOMMENDED APPROVAL |
RANK/RATE/TITLE: |
SIGNATURE: |
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DATE: |
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YES |
NO |
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19. |
RECOMMENDED APPROVAL |
RANK/RATE/TITLE: |
SIGNATURE: |
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DATE: |
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YES |
NO |
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20. |
RECOMMENDED APPROVAL |
RANK/RATE/TITLE: |
SIGNATURE: |
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DATE: |
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YES |
NO |
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21. |
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SIGNATURE: |
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APPROVED |
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DISAPPROVED |
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22. REASON FOR DISAPPROVAL: |
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NAVPERS 1336/3 (Rev. 10-2011) |
FOR OFFICIAL USE ONLY - PRIVACY SENSITIVE |
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