Leave & Pass Request Form

Leave & Pass Request AFZH-CEB-H

DATE:___________

MEMORANDUM FOR: Commander, HHD, 23d Chemical Battalion SUBJECT: Request and Authority:

3 Day Pass

4 Day Pass

Mileage Pass

Leave

1. Request and authority for pass in accordance with AR 600-8-10. NAME:___________________________ SSN:__________________ RANK:______ PLATOON:______ SECTION:__________ DATE ASSIGNED:________ LAST PASS:__________ START DATE:_____________________ END DATE:______________________ ADDRESS: __________________________________________________ TELEPHONE NUMBER:_________________________ REASON FOR PASS: 2. The squad leader has verified the following categories: a. Company CQ/CQR: b. Is the soldier scheduled to attend school: c. Has the soldier passed the APFT: d. Has the soldier qualified with assigned weapon: e. Is the soldier flagged: f. Soldier has a round trip ticket: N/A g. Soldier has alert roster:

YES YES YES YES YES YES YES

NO NO NO NO NO NO NO

Replacement:______________ Date:_________ Date:_________ Reason:_____________ Return Date:________

Squad Leader:_______________________________________

RECOMMENDATION Approval Disapproval

Section/Platoon Sergeant:______________________________

Approval

Disapproval

Primary Staff Officer/NCOIC:__________________________

Approval

Disapproval

First Sergeant:_______________________________________

Approval

Disapproval

Commander:________________________________________

Approval

Disapproval

Reason for Disapproval:

DATA REQUIRED BY THE PRIVACY ACT OF 1974: AUTHORITY: Title 5, USC, Section 301. Purpose to authorize military leave, document start and stop of such leave: record address and telephone number where a soldier maybe contacted in case of an emergency during leave; and certifies leave days chargeable to a soldier’ s leave account. ROUTINE USES: to update a soldier’s military and pay records, information furnished may be disclosed to DOD official or employees who need this information to perform their duties: To federal, state, and local law enforcement authorities in appropriate cases: the American Red Cross; and relatives. The social security number is used for positive identification. DISCLOSURE: Voluntary. Disclosure of SSN is voluntary. However this form will not be processed without a soldier’s SSN, since the Army identifies members for pay or leave purposes.