Special Request/authorization Form
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1SPECIAL REQUEST/AUTHORIZATION
SUPPORTING DIRECTIVE MILPERSMAN ARTICLES
1810-010 AND 1810-040
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:
2. RATE:
3. SHIP OR STATION:
4. DATE OF REQUEST:
(YYYYMMDD)
5. DEPARTMENT/DIVISION:
6. DUTY SECTION/GROUP:
7. NATURE OF REQUEST:
SPECIAL
COMMUTED
OTHER
LEAVE
SPECIAL PAY
LIBERTY
RATIONS
(BELOW)
FROM (DATE AND TIME):
8. NO. OF DAYS REQUESTED:
TO (DATE AND TIME):
MODE OF TRAVEL:
9. DISTANCE (MILES):
CAR
AIR
TRAIN
BUS
10. LEAVE ADDRESS:
11. TELEPHONE NUMBER:
12. REASON FOR REQUEST:
R/R to attend NTTC Class XXXXX (DDMMYY to DDMMYY). Deployment date: DDMMYY. Platform/Deploying to:XXXXXX.
Requires Director (and DNS for NC) approval. Approval implies verification of deployment by Chain of Command.
13. SIGNATURE OF APPLICANT: (Use CAC for digital signature)
DUTY STATION:
SIGNATURE OF STANDBY:
. I am eligible and obligate myself to
14
perform all duties of person making
application.
15. RECOMMENDED APPROVAL
SIGNATURE:
DATE:
RANK/RATE/TITLE:
YES
NO
16. RECOMMENDED APPROVAL
RANK/RATE/TITLE:
SIGNATURE:
DATE:
YES
NO
17. RECOMMENDED APPROVAL
SIGNATURE:
DATE:
RANK/RATE/TITLE:
YES
NO
18. RECOMMENDED APPROVAL
SIGNATURE:
DATE:
RANK/RATE/TITLE:
YES
NO
19. RECOMMENDED APPROVAL
DATE:
RANK/RATE/TITLE:
SIGNATURE:
YES
NO
20. RECOMMENDED APPROVAL
DATE:
SIGNATURE:
RANK/RATE/TITLE:
YES
NO
21.
SIGNATURE:
APPROVED
DISAPPROVED
22. REASON FOR DISAPPROVAL:
NAVPERS 1336/3 (Rev. 02-2011)
FOR OFFICIAL USE ONLY - PRIVACY SENSITIVE
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