Dd Form 2539 - Voluntary Leave Transfer Program Leave Recipient Application
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11. PAYBLOCK NUMBER
VOLUNTARY LEAVE TRANSFER PROGRAM
LEAVE RECIPIENT APPLICATION
PRIVACY ACT STATEMENT
EO 9397, November 1943 (SSN).
AUTHORITY:
PRINCIPAL PURPOSE(S):
Individuals wishing to participate in the Voluntary Leave Transfer Program as recipients
of leave make application by completing this form. The information provided is used to
validate the applicant's request.
ROUTINE USE(S):
None.
DISCLOSURE:
Voluntary; however, failure to provide requested information may impede the validation
process.
2. EMPLOYEE IDENTIFICATION
a. NAME (Last, First, Middle Initial)
b. SOCIAL SECURITY NO.
c. POSITION TITLE
d. GRADE/STEP
e. ORGANIZATION
f. SALARY
3. LEAVE DATA
a. AS OF (YYMMDD)
b. ANNUAL LEAVE
c. SICK LEAVE BALANCE d. DATE AVAILABLE LEAVE
e. ACCRUAL RATE FOR ANNUAL
BALANCE
EXPIRES (YYMMDD)
LEAVE
4. MEDICAL EMERGENCY
a. DESCRIPTION (Attach appropriate documentation)
b. EXPECTED DURATION
c. APPROXIMATE FREQUENCY (If recurring)
5. CONTACT DURING PERIOD OF EMERGENCY
a. EMPLOYEE TELEPHONE
b. OTHER POINT OF CONTACT (If applicable)
NUMBER (If available)
(1) Name (Last, First, Middle Initial)
(3) Address (Street, City, State and Zip Code)
(Include Area Code)
(2) Telephone Number (Include Area Code)
6. EMPLOYEE CERTIFICATION
I am aware that publication of all or part of the above information may be necessary to find leave donors.
a. SIGNATURE
b. DATE SIGNED (YYMMDD)
7. SUPERVISOR APPROVAL
a. SIGNATURE
b. DATE SIGNED (YYMMDD)
DD FORM 2539, MAY 89
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