APPLICATION FOR THE REVIEW OF DISCHARGE
OMB No. 0704-0004
FROM THE ARMED FORCES OF THE UNITED STATES
OMB approval expires
Dec 31, 2017
(Please read Privacy Act Statement and Instructions on Pages 3 and 4 BEFORE completing this application.)
The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(0704-0004). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a
currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. RETURN COMPLETED FORM TO THE APPROPRIATE ADDRESS ON BACK OF THIS PAGE.
1. APPLICANT DATA
. PLEASE PRINT OR TYPE INFORMATION.
(The person whose discharge is to be reviewed)
a. BRANCH OF SERVICE (X one)
c. GRADE/RANK AT DISCHARGE
d. SOCIAL SECURITY NUMBER
b. NAME (Last, First, Middle Initial)
e. CURRENT MAILING ADDRESS OF APPLICANT OR PERSON NAMED IN ITEM 11
f. TELEPHONE NUMBER (Include Area Code)
(Forward notification of any change in address.)
h. FAX NUMBER (Include Area Code)
4. DISCHARGE CHARACTERIZATION RECEIVED
5. BOARD ACTION REQUESTED
(X all that apply)
2. DATE OF DISCHARGE OR SEPARATION
(YYYYMMDD) (If date is more than 15 years
CHANGE TO HONORABLE
ago, submit a DD Form 149)
CHANGE TO GENERAL/UNDER HONORABLE
GENERAL/UNDER HONORABLE CONDITIONS
3. UNIT AND LOCATION AT DISCHARGE
CHANGE TO UNCHARACTERIZED (Not applicable
UNDER OTHER THAN HONORABLE CONDITIONS
to Air Force or service members with over 6 months of
BAD CONDUCT (Special Court-Martial only)
CHANGE NARRATIVE REASON FOR
6. ISSUES: WHY AN UPGRADE OR CHANGE IS REQUESTED AND JUSTIFICATION FOR THE REQUEST
(Continue in Item 13. See instructions on Page 3.)
AN APPLICATION WAS PREVIOUSLY SUBMITTED ON
(X if applicable)
AND THIS FORM IS SUBMITTED TO ADD ADDITIONAL ISSUES, JUSTIFICATION, OR EVIDENCE.
8. IN SUPPORT OF THIS APPLICATION, THE FOLLOWING ATTACHED DOCUMENTS ARE SUBMITTED AS EVIDENCE:
(Continue in Item 14.
If military documents or medical records are relevant to your case, please send copies.)
9. TYPE OF REVIEW REQUESTED
CONDUCT A RECORD REVIEW OF MY DISCHARGE BASED ON MY MILITARY PERSONNEL FILE AND ANY ADDITIONAL DOCUMENTATION SUBMITTED BY ME.
I AND/OR (counsel/representative) WILL NOT APPEAR BEFORE THE BOARD.
I AND/OR (counsel/representative) WISH TO APPEAR AT A HEARING AT NO EXPENSE TO THE GOVERNMENT BEFORE THE BOARD IN THE WASHINGTON, D.C.
I AND/OR (counsel/representative) WISH TO APPEAR AT A HEARING AT NO EXPENSE TO THE GOVERNMENT BEFORE A TRAVELING PANEL CLOSEST TO
(enter city and state)
(NOTE: The Naval and Coast Guard Discharge Review Boards do not have traveling panels.)
(Last, First, Middle Initial)
b. TELEPHONE NUMBER (Include Area Code)
(See Item 10 of the instructions about counsel/representative.)
d. FAX NUMBER (Include Area Code)
11. APPLICANT MUST SIGN IN ITEM 12.a. BELOW. If the record in question is that of a deceased or incompetent person, LEGAL PROOF OF
DEATH OR INCOMPETENCY MUST ACCOMPANY THE APPLICATION. If the application is signed by other than the applicant, indicate the
and relationship by marking a box below.
NEXT OF KIN
I make the foregoing statements, as part of my claim, with full knowledge of the penalties
involved for willfully making a false statement or claim. (U.S. Code, Title 18, Sections 287 and 1001, provide
(Do not write in this space.)
that an individual shall be fined under this title or imprisoned not more than 5 years, or both.)
a. SIGNATURE - REQUIRED (Applicant or person in Item 11 above)
b. DATE SIGNED - REQUIRED (YYYYMMDD)
DD FORM 293, DEC 2014
PREVIOUS EDITION IS OBSOLETE.
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