This form is subject to the Privacy Act of 1974. For use of this form, see AR 600-8-10. The proponent agency is ODCSPER. (See Instructions on Reverse)1. CONTROL NUMBER
2. NAME (Last, First, Middle Initial)
6. LEAVE ADDRESS (Street, City, State, ZIP Code and
Phone No.)7. TYPE OF LEAVE
8. ORGN, STATION, AND PHONE NO.
0 PERMISSIVE TDY
9.NUMBER DAYS LEAVE10.DATES
11. SIGNATURE OF REQUESTOR
12. SUPERVISOR RECOMMENDATION/SIGNATURE
1 APPROVAL 0 DISAPPROVAL
13. SIGNATURE AND TITLE OF
c. NAME/TITLE/SIGNATURE OF DEPARTURE AUTHORITY
a. NUMBER DAYS
b. DATE APPROVED
c. NAME/TITLE/SIGNATURE OF APPROVAL AUTHORITY
c. NAME/TITLE/SIGNATURE OF RETURN AUTHORITY
I understand that this absence is not directed by any official of the U.S. Government. I further understand that I cannot conduct public business under this authorization. Accordingly, I will not be entitled to reimbursement for travel, per diem, or any other expenses. I understand that I have the right to cancel it at any time and return to my regular place of duty.
Chargeable Leave is from to
Chargeable leave is from to
PART II - EMERGENCY LEAVE TRANSPORTATION AND TRAVEL
18. You are authorized to proceed on official travel in connection with emergency leave and upon completion of your leave and travel will return...