Form 4126 - Bar To Reenlistment Certificate Page 2
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1
2SECTION II - SOLDIER'S REVIEW
17. I understand that by placing my initials on the line by the statement below I am confirming the action to be true and complete.
I have been counseled and advised of the basis for this action.
a.
I have been furnished a copy of my Commander's recommendation
(Sec 1 to bar me from further reenlistment.
b.
DO NOT desire to submit a statement in my own behalf
(use a continuation sheet if required.)
I
DO/
c.
18. NAME AND RANK OF SOLDIER
19. SIGNATURE
20. DATE
SECTION III - NEXT HIGHER COMMAND
21. Unit/Organization
22. I have reviewed Sections I and II and all factual and relevant information (enclosures).
a.
Recommend Approval of the Bar to Reenlistment.
(The Bar certificate and enclosures will be forwarded to the next higher commander)
b.
The Bar Certificate is Disapproved.
The Bar Certificate is Approved.
c.
The unit commander will officially counsel the Soldier in writing on the implications of this action and the Soldier's right to appeal. After
counseling, the Bar certificate and enclosures will be forwarded to the servicing Career Counselor (PMOS 79S) for appropriate filing and
administrative actions.
23. NAME AND RANK OF COMMANDER
24. SIGNATURE
25. DATE
SECTION IV - COUNSELING BY INITIATING COMMANDER
26. The Bar to Reenlistment initiated against you was approved on
.
27. I understand a Bar to Reenlistment is a rehabilitative action. I further understand, if I fail to make progress I may be subject to involuntary
separation.
28. You have the right to appeal the imposition of the Bar to Reenlistment. If you elect to appeal you must submit the appeal within 7 days of
this counseling.
29. Initial the appropriate block to indicate your option:
a. I will appeal the Bar to Reenlistment.
b. I will not appeal the Bar to Reenlistment.
If appealing the Bar, my appeal is due to my commander no later than close of business on
.
30. NAME AND RANK OF SOLDIER
31. SIGNATURE
32. DATE
33. NAME AND RANK OF COMMANDER
34. SIGNATURE
35. DATE
DA FORM 4126, XXX 2014
Page 2 of 2
APD LC v1.00ES
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