Dd Form 2715-3 - Prisoner Restoration/return To Duty, Clemency And Parole Statement Page 2

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SECTION III - PAROLE
13. UNDER REGULATION I BECOME ELIGIBLE FOR PAROLE CONSIDERATION ON (YYYYMMDD):
14.
I DESIRE
DO NOT DESIRE TO BE CONSIDERED FOR PAROLE FOR THE FOLLOWING REASONS:
15. PROPOSED PAROLE RESIDENCE
:
(State fully where and with whom you will live)
a. NAME
b. RELATIONSHIP
c. TELEPHONE NUMBER
(Last, First, Middle Initial)
(Include area code)
d. STREET ADDRESS
e. CITY
f. STATE
g. ZIP CODE
(Include apartment number)
16. PROPOSED
EMPLOYER
SCHOOL
a. EMPLOYER OR SCHOOL NAME
b. TELEPHONE NUMBER
(Include area code)
c. STREET ADDRESS
d. CITY
e. STATE
f. ZIP CODE
(Include apartment number)
g. TITLE OR POSITION
h. RATE OF PAY
(1) FULL TIME
(2) PART TIME
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 874(a), 952-954; DoD Instruction 1325.07; and E.O. 9397.
PRINCIPAL PURPOSE(S): To allow official military personnel to review requests for restoration/return to duty, clemency, or parole and provide
recommendations to the appropriate Military Service Clemency and Parole Board.
ROUTINE USE(S): The DoD "blanket routine uses" found at apply to the
completed form.
DISCLOSURE: Voluntary; however, failure to provide the requested information may prevent the Board from considering your eligibility for clemency
or parole.
17. PRISONER/SUPERVISEE SIGNATURE
18. DATE
(YYYYMMDD)
19. WITNESS NAME
, GRADE, TITLE
20. SIGNATURE
21. DATE
(Last, First, Middle Initial)
(YYYYMMDD)
DD FORM 2715-3, MAR 2013
Page 2 of 2 Pages

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