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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   | Action           |   | File              |   |   | N |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   | Approval         |   | For Clearance     |   |   | P |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   | As Requested     |   | For Correction    |   |   | P |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   | Circulate        |   | For Your          |   |   | S |        |         |
|   |                  |   | Information       |   |   | e |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   | Comment          |   | Investigate       |   |   | S |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   | Coordination     |   | Justify           |   |   |   |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   |                  |   |                   |   |   |   |        |         |
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+---+------------------+---+-------------------+---+---+---+--------+---------+
|   |                  |   |                   |   | P |   |        |         |
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|   |                  |   |                   |   | . |   |        |         |
+---+------------------+---+-------------------+---+---+---+--------+---------+
|   |                  |   |                   |   |   |   |        |         |
|   |                  |   |                   |   |   |   |        |         |
|   |                  |   |                   |   |   |   |        |         |
|   |                  |   |                   |   |   |   |        |         |
|   |                  |   |                   |   |   |   |        |         |
+---+------------------+---+-------------------+---+---+---+--------+---------+

Locally produced form. **OPTIONAL FORM 41** (Rev. 1-94)

PPQ WRO, 2150 Centre Ave, Fort Collins, CO 80526 Prescribed by GSA