(towsoaioAO0e2| | = KEQUESIT TOK PERSONNEL ACIION ca o | [JE PON re OLA SITs ad 3 rr es SER ZT NUMER Dearrlleryagne : (Sackoround Use Only ‘ {De Nos Reoreduce fy See ! ve "ope Hie Noman vMOtoC] oo: HIC'NS, CALVvIn by & 2 NATURE OF PERSONNEL xetret &. EFFECTIVE DATE RFQUESTED 5. CATEGORY OF EMPLOYMENT MONTH Day YEAR 17. FINANCIAL ANALYSIS B. LEGAL AUTHORITY (Completed by Office of sy, | . vTOV v 10 ¢F NO. CHARGEABLE Personnel ) & FLWDS > an . v F am 9 ~ oe oes oe | lerre T285 O45 © CPLANIZATIONAL DESIGNATIONS 10. LOCATION OF OFFICIAL STATION 14) POSITION TITLE 12. POSITION NUMBER 13. CAREER SERVICE DESIGNATION 14, CLASSIFICATION SCHEDULE (GS. LB. ete.) . OCCUPATIONAL SERIES 16. GRADE AND STEP or iat . REMARKS Phors ogop/eu/cs uyevs 5 a en PIRSA ste Be SECURITY Date: Security Anprove] the ,ase conigi weit eee Ue Chief, Personnel 18M. SIGNATURE OF REQUESTING OFFICIAL DATE SIGNED 188. SIGNATURE OF CAREER SERVICE APPROVING OFFICER DATE SIGNED SPACE BELOW FOR EXCLUSIVE USE OF THE OFFICE OF PERSONNEL 19, ACTION | 20. EMPLOY. | 29. OFFICE CODIRG 22. STATION 73. INTEGREE 24. HDQURS.1 25. DATE OF BIRTH 26. DATE OF GRADE 27. DATE OF LE . . . : . 30. RETIREMENT DATA 31. SEPARATION | 32. CORRECTION /CANCELLATION DATA : Hi. SERV. COMP. DATE 37. LONG. COMP. DATE 38. CAREER CATEGORY 39. FEGLI (HEALTH INSURANCE mo. MOo.- Da. va. Da. YR. CAR /RESY CODE CODE | 0O—WAIVER HEALTH INS. CODE PROV /TEMP 1 YES 43. FEDERAL TAX DATA 44. STATE TAX DATA 29. SPECIAL REFERENCE 33. SECURITY REQ. NO. 28. NTE EXPIRES MO. DA, YR. 40. SOCIAL SECURITY RO. 41. PREVIOUS CIVILIAN GOVERNMENT SERVICE 42. LEAVE CAT. CODE cope O—RO PREVIOUS SERVICE FORM EXECUTED | CODE NO. TAX EXEMPTIONS | FORM EXECUTED STATE CODE 1—HO GREAK IR SERVICE YES. 2— BREAK IN SERVICE (LESS THAN 3 YEARS) 2—KO 3—BREAK IM SERVICE (MORE THAN 3 YEARS) 45. POSITION CONTROL CERTIFICATION 46. O.P. APPROVAL DATE APPROVED metre ermrinan wee 152 use GROUP i | 4 _ ” meee ON O SECRET EXCLUGED FROM AUTOMATIC DOW NGRADIKG E - l AKD DECLASSIFICATION ;
14-00000 | RESIGN EFFECTIVE __, FOR THE FOLLOWING REASON. ETE Ser ney : » (Date) . a ot ca i 4 . « . ® + i un “~ a re | Str gaan .- J 20 Fit ps : PAY Dring, i MY LAST WORKING DAY WILL BE— DATE SIGNED SIGNATURE OF EMPLOYEE FORWARD COMMUNICATIONS, INCLUDING SALARY CHECKS AND BONDS, TO THE FOLLOWING ADDRESS (Number, Street, City, State. Zip Code) Irems 11 and 15 ~ “Position Title” and “Occupational Series” should be the standard abbreviated title and corresponding occupational series in Handbook of Official Occupational Titles and Codes for the duties actually to be performed by the employee. If different from the title and series of the position occupied as shown on the most current edition of the Position Con- trol Register or Form 261, Staffing Complement Change Authorization, explain under Item 18—Remarks. j i INSTRUCTIONS i \ i Items 1 thru? ) The initiating office should fill in each of the referenced items. Items 3 thru 7 and 9 thru | and — 18 require information which pertains ov/y to the action requested, and NOT to the current : Jrems 9 thru 18a status of the employee unless specific items remain unchanged. ceece : . @ e e : Item: 5 ~ “Category of Employment" should show one of the following entries: ° j e"*e : Regular Summer WAE eee { Part Time Detail Our Consultant . ' Temporary Detail In Military * eet? : Temporary-Part Time . . . : see i Item 9 — “Organizational Designations” should show a// levels of organization pertinent to idepgify- ing the location of the position: , eeeve 3y | Major Component (Director, Deputy Director, etc.) crete ated Office, Major Staff, etc. eceee Foreign Field or U.S. Field (sf pertinent) , ° Division or Staff (subordinate to first line) 2 6 Branch :*.° Section Unit { Item 18b ~ Signature should be that of the official authorized to approve for the Career Service to which the employee belongs. If more than one Career Service is involved, the gaining Career Serv- ice should approve and the other Career Service should concur in Item 18, Remarks. ’ . . ROUTING-— The original only of this form will be forwarded to the Office of Personnel through the appropriate Career Service official(s). In the case of requests specified in HB 20-800~1, which require advance - approval of or notification to the Office of Security or the Office of the Comptroller, one copy only will be sent to the OMcels) concerned. : > — seca tt me tne