Authentication and Emergency Leave Transportation

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REQUEST AND AUTHORITY FOR LEAVE
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

PART I
2. NAME (Last, First, Middle Initial)
3. SSN
4. RANK
5. DATE

6. LEAVE ADDRESS (Street, City, State, ZIP Code and
Phone No.)7. TYPE OF LEAVE
1ordinary

0 EMERGENCY
8. ORGN, STATION, AND PHONE NO.

0 PERMISSIVE TDY
0other

_____________________________
9.NUMBER DAYS LEAVE10.DATES
a. ACCRUED
b. REQUESTED
c. ADVANCED
d. EXCESS
a. FROM
b. TO

11. SIGNATURE OF REQUESTOR

12. SUPERVISOR RECOMMENDATION/SIGNATURE
1 APPROVAL 0 DISAPPROVAL

13. SIGNATURE AND TITLE OF
APPROVING AUTHORITY

14.DEPARTURE
a. DATE

b. TIME

c. NAME/TITLE/SIGNATURE OF DEPARTURE AUTHORITY

15.EXTENSION
a. NUMBER DAYS

b. DATE APPROVED

c. NAME/TITLE/SIGNATURE OF APPROVAL AUTHORITY

16.RETURN
a. DATE

b. TIME

c. NAME/TITLE/SIGNATURE OF RETURN AUTHORITY

17. REMARKS
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...
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