Special Request Chit
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SPECIAL REQUEST/AUTHORIZATION NAVPERS 1336/3 (Rev. 9-75) SIN 106-LF-063-8633 PRIVACY ACT STATEMENT The authority to request this information is contained in 5 USC
employees of the Department of the Navy in determining your
301, Departmental Regulations. The principal purpose of the in-
eligibility for and approving or disapproving the special considera-
formation is to enable you to make known your desire for one
tion or authorization being requested. Completion of the form is
of the four name listed or for some other special consideration or authorization. The information will be used to assist officals and
mandentory; failure to provide required information may result in delay in response to or disapproval of your request.
_
SSN
RATE
NAME
DATE OF REQUEST
SHIP OR STATION
DEPARTMENT / DIVISION / WARD
DUTY SECTION / GROUP
NATURE OF REQUEST SPECIAL LIBERTY
LEAVE NO. DAYS REQUEST
DISTANCE (Miles)
SPECIAL PAY
COMMUTED RATIONS
OTHER (Below)
TO (Date and Time)
FROM (Date and Time)
MODE OF TRAVEL AIR
TRAIN
BUS
CAR TELEPHONE NUMBER
LEAVE ADDRESS (Street, box Or route number., City, State, Zip Code)
REASON FOR REQUEST
SIGNATURE OF APPLICANT:
I AM ELIGIBLE AND OBLIGATE MYSELF TO PERFORM ALL DUTIES OF PERSON MAKING APPLICATION SIGNATURE OF STANDBY DUTY STATION
PERSONNEL OFFICE LEAVE THIS FISCAL YEAR
EARNED LEAVE
DATE LAST PAID
DAYS AS OF: SIGNATURE AND RANK / RATE / TITLE / DATE
RECOMMENDED APPROVAL YES
NO
YES
NO
SIGNATURE AND RANK / RATE / TITLE / DATE
SIGNATURE AND RANK / RATE / TITLE / DATE YES
NO
YES
NO
APPROVED
DISAPPROVED
SIGNATURE AND RANK / RATE / TITLE / DATE
SIGNATURE
REASON FOR DISAPPROVAL
LOG OUT AND IN WITH OOD (When required) OUT (Hour and date)
INITIALS 00D
IN (Hour and date)
HITCHHIKING IS PROHIBITED
INITIALS 000
• U.S.GPO:1994-505-188
employees of the Department of the Navy in determining your
301, Departmental Regulations. The principal purpose of the in-
eligibility for and approving or disapproving the special considera-
formation is to enable you to make known your desire for one
tion or authorization being requested. Completion of the form is
of the four name listed or for some other special consideration or authorization. The information will be used to assist officals and
mandentory; failure to provide required information may result in delay in response to or disapproval of your request.
_
SSN
RATE
NAME
DATE OF REQUEST
SHIP OR STATION
DEPARTMENT / DIVISION / WARD
DUTY SECTION / GROUP
NATURE OF REQUEST SPECIAL LIBERTY
LEAVE NO. DAYS REQUEST
DISTANCE (Miles)
SPECIAL PAY
COMMUTED RATIONS
OTHER (Below)
TO (Date and Time)
FROM (Date and Time)
MODE OF TRAVEL AIR
TRAIN
BUS
CAR TELEPHONE NUMBER
LEAVE ADDRESS (Street, box Or route number., City, State, Zip Code)
REASON FOR REQUEST
SIGNATURE OF APPLICANT:
I AM ELIGIBLE AND OBLIGATE MYSELF TO PERFORM ALL DUTIES OF PERSON MAKING APPLICATION SIGNATURE OF STANDBY DUTY STATION
PERSONNEL OFFICE LEAVE THIS FISCAL YEAR
EARNED LEAVE
DATE LAST PAID
DAYS AS OF: SIGNATURE AND RANK / RATE / TITLE / DATE
RECOMMENDED APPROVAL YES
NO
YES
NO
SIGNATURE AND RANK / RATE / TITLE / DATE
SIGNATURE AND RANK / RATE / TITLE / DATE YES
NO
YES
NO
APPROVED
DISAPPROVED
SIGNATURE AND RANK / RATE / TITLE / DATE
SIGNATURE
REASON FOR DISAPPROVAL
LOG OUT AND IN WITH OOD (When required) OUT (Hour and date)
INITIALS 00D
IN (Hour and date)
HITCHHIKING IS PROHIBITED
INITIALS 000
• U.S.GPO:1994-505-188
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