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REQUEST AND AUTHORITY FOR LEAVE
This form is subject to the Privacy Act of 1974. For use of this form, see AR 600-8-10.
The proponent agency is ODCSPER. (See instructions on reverse.)
28. DATE ISSUED
13. SIGNATURE AND TITLE OF
APPROVING AUTHORITY
6. LEAVE ADDRESS (Street, City, State, ZIP Code and
Phone No.)
24
.
PART III - DEPENDENT TRAVEL AUTHORIZATION
EXTENSION
15.
EDITION OF 1 AUG 75 IS OBSOLETE
PART I
7. TYPE OF LEAVE
ORDINARY
EMERGENCY
PERMISSIVE TDY OTHER
NUMBER DAYS LEAVEDATES10.9.
12. SUPERVISOR RECOMMENDATION/SIGNATURE
APPROVAL DISAPPROVAL
DEPARTURE14.
RETURN16.
PART IV - AUTHENTICATION FOR TRAVEL AUTHORIZATION
a. DEPENDENTS (Last name, First, MI)b. RELATIONSHIPc. DATES OF BIRTH (Children)d. PASSPORT NUMBER
DEPENDENT INFORMATION
25.
Chargeable leave is from to
PART II - EMERGENCY LEAVE TRANSPORTATION AND TRAVEL
18. You are authorized to proceed on official travel in connection with emergency leave and upon completion of your leave and travel will
return to home station (or location) designated by military orders. You are directed to report to the Aerial Port of Embarkation (APOE) for
onward movement to the authorized international airport designated in your travel documents. All additional travel is chargeable to leave. Do
not depart the installation without reservations or tickets for authorized space required transportation. File a no-pay travel voucher with a copy
of your travel documents or boarding pass within 5 working days after your return. Submit request for leave extension to your commander.
The American Red Cross can assist you in notifying your commander of your request for extension of leave.
(Space required) TRANSPORTATION AUTHORIZED FOR DEPENDENTS LISTED IN BLOCK NO. 25
(Space available or required cash reimbursable) ONE WAY
ROUND TRIP
USAPPC V4.00
1. CONTROL NUMBER
2. NAME (Last, First, Middle Initial) 3. SSN 4. RANK5. DATE
8. ORGN, STATION, AND PHONE NO.
a. ACCRUEDb. REQUESTEDc. ADVANCEDd. EXCESSa. FROMb. TO
11. SIGNATURE OF REQUESTOR
a. DATE b. TIME c. NAME/TITLE/SIGNATURE OF DEPARTURE AUTHORITY
a. NUMBER DAYSb. DATE APPROVEDc. NAME/TITLE/SIGNATURE OF APPROVAL AUTHORITY
a. DATE b. TIME c. NAME/TITLE/SIGNATURE OF RETURN AUTHORITY