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CAUTION: NOT TO BE USED FOR A j THFS 1. IMPORTANT RE RDANY ALTERATIONS IN SHADED <br />IDENTIFICATION PURPOSES SAFEGUARD 1T �� AREAS RENDER FORM VOID <br />PREVIOUSFORMARDITIONS OF TE <br />ODUTY EASE OR DISCHARGE <br />DD I JQUR 9 214 OBSOLETE.HIS <br />FROM ACTIVECERTIFICATE <br />25. SEPARATION AUTHOR" <br />26. SEP4RATION CODE <br />1. NAME (Last, firs; middle) <br />2. DEPARTMENT, COMPONENT AND BRANCH <br />3. SOCIAL <br />SECURITY NO, <br />28. NARILATIVE REASON F R SEPARATION <br />u�, TTS -1a_ I�-+i <br />t��l�n <br />5�:> <br />4Is. GRADE, RATE OR RANK bb. PAY GRADE <br />Z r� <br />IS. DATE OF BIRTH <br />61a; 0l} <br />6. PLACE OF ENTRY INTO ACTIVE DUTY <br />i'resDoq Ci <br />7. LAST DUTY ASSIGNMENT / �ANi}DTTrt1Mnf AIOR COMMAND r� 1 <br />Go �' 6Lh Hn (V UR) 1$4t sm UG_,i l/&m- r °SOV <br />8. STATION WHERE SEPARATED <br />POrh Gordon, Ci <br />9. COMMAND TO WHICH TRANSFERRED <br />10. SGU COVERAGE <br />FIA <br />AMOUNTS %(% <br />000 <br />NONE <br />11. PRIMARY SPECIALTY NUMBER, TIRE AND YEARS AND <br />MONTHS IN SPECIALTY (Additional specialty numbers and eftles <br />involvingperiods of one or moreyears) <br />12. RECORD OF SERVICE. YEAR (s) <br />MON (s) DAY (s) <br />e. Date Entered AD This Period <br />b. SaOorolian Dole This Period <br />G Not Active Service This Period <br />361',00 Basic Trd-nae <br />d. Tola1 Prior Active Service { <br />! <br />e. Total Prior Inactive Servka 4J0 <br />03 <br />E Foreign Servlca 00 <br />L�.•:''�� <br />Ly <br />g• Sea Servke T� <br />U� <br />C-0 <br />- <br />b. Effective Dore of P., Grade - �,ii <br />O.L <br />- I <br />L Reaane Oblig, Term. Date ri <br />13. DECORATIONS. MEDALS. BADGES, CITATIONS AND CAMPAIGN RIBBONS AWARDED OR AUTHORIZED (Allperiods of service) <br />liar��SeTl2S3 �7'Zl.=,)f .ISS'b9T+-j; �ij3i,11 !��eZ=LTB; <br />Id. MILITARY EDUCATION (Course Title, numberureehs, and month and year completed) <br />15. MEMBER CONTRIBUTED TO POST -VIETNAM ERA <br />VETERANS' EDUCATIONAL ASSISTANCE PROGRAM ElYES El NO <br />16. HIGH SCHOOL GRADUATE OR EQUIVALENT <br />© YES NO <br />17. DAYS ACCRUED <br />LEAVE PAID <br />L <br />18. REMARKS <br />I <br />.19. MAULING ADDRESS AFTER SEPARATION <br />11-2-0 }:;h0lh%=' <br />JGO�'=L4n, Cd_ 95:2,36 <br />20. MEMBER REQUESTS COPY 6 BE <br />SENT TO `'=, DIR. OF VET <br />AFFAIRS YES ❑PJO <br />21. SIGNATURE OF MEMBER BEING <br />}�SEPARATED <br />7 % 22. TYPED NAh2E.GRADE, TITLJANDBSIGNATURE OF OFFICIAL <br />AVMORIZED TA S .x'• _ <br />SPECIAL ADDITIONAL INFORMATION (For use by authorised agencies only) <br />23. TYPE OF SEPARATION <br />24. CHARACTER OF SERVICE (Includes upgrades) <br />are <br />Honorable <br />25. SEPARATION AUTHOR" <br />26. SEP4RATION CODE <br />27. REENUSTMENT CODE <br />AR 6'11-200 <br />JET <br />3 <br />28. NARILATIVE REASON F R SEPARATION <br />m—A..As TL e..l,ay..rc Pvnrrv�aan (qmp) Mardi nal nr ATnttn'i+nrlTTrvhiSrR <br />