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: YES NO Replacement:______________
b. Is the soldier scheduled to attend school: YES NO
c. Has the soldier passed the APFT: YES NO Date:_________
d. Has the soldier qualified with assigned weapon: YES NO Date:_________
e. Is the soldier flagged: YES NO Reason:_____________
f. Soldier has a round trip ticket: N/A YES NO Return Date:________
g. Soldier has alert roster: YES NO

RECOMMENDATION
Squad Leader:_______________________________________ 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.