Dd Form 2648 - Preseparation Counseling Checklist For Active Component (Ac), Active Guard Reserve (Agr), Active Reserve (Ar), Full Time Support (Fts), And Reserve Program Administrator (Rpa) Service Members Page 5

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NAME
SSN
(Last, First, Middle Initial)
PRESEPARATION COUNSELING
CHECKLIST FOR AC, AGR, AR,
FTS, AND RPA SERVICE
MEMBERS
SECTION VI - REMARKS
(Attach additional pages if necessary)
Complete the following ONLY if you placed an X in Item 8.a. (See page 1, Section II, item 8.a.)
27. MY COUNSELING WAS CONDUCTED 89 DAYS OR LESS BEFORE MY SEPARATION OR RETIREMENT BECAUSE OF: (X one)
Mission requirements
Legal separation
Change in career decision
Personal reasons
Medical separation/discharge
Other (Please provide a brief explanation)
Pre-Separation Interview was conducted on _________________ by
________________________, Unit Transition Counselor
UTC Signature
_________________________________________________
UTC Printed Name
Unit__________________________________
28. SERVICE MEMBER ACKNOWLEDGEMENT
By signing and dating this form, you, the Service member, are acknowledging that you received Preseparation Counseling on the date below
(item 28.b.), and that you understand the transition benefits and services available to assist you in your transition as required by Title 10,
U.S.C., Chapter 58, Section 1142.
a. SERVICE MEMBER SIGNATURE
b. DATE
c. TRANSITION COUNSELOR SIGNATURE
d. DATE
(YYYYMMDD)
(YYYYMMDD)
DD FORM 2648 TEST, JAN 2011
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