(404-10128-10260 . oe ~ yo SECRET - (When Filled In) . DATE PREPARED . REQUEST FOR PERSONNEL ACTION 1, SERIAL NUMBER 2. NAME (Last—First— Middle) 3. NATURE OF PERSONNEL ACTION 4A. EFFECTIVE DATE REQUESTED 5. CATEGORY OF EMPLOYMENT MONTH DAY 2s ieee NMG « 7, FINANCIAL ANALYSIS NO. /@. LEGAL AUTHORITY (Completed by Office of | VTOV ; V10 CHARGEABLE Personnel) 6. FUNDS 9. ORGANIZATIONAL DESIGNATIONS DDP/WH FOREIGN FIELD BRANCH 5 (6 11, POSITION THLE 17. SALARY OR RATEC? FSR . 23, 646.. bot & AC A.” 18. REMARKS FROM: DDP/WH/COG/OFF OF THE CH/POS #1105 HOME BASE WH APPROVED 2592 attached 1 - Finance 2«~ Security 18A, SIGNATURE OF REQUESTING OFFICIAL BATE SIGNED 186. si HENRY L. BERTHOLD (Gn / Pers SPACE BELOW FOR EXCLUSIVE US€ OF THE OFFICE OF PERSONNEL 19. ACTION | 20. EMPLOY. | 21. OFFICE CODING 23. i 24. HDQTRS.| 25. DATE OF BIRTH 26. BATE OF GRADE : ~ ~ aia 28. NTE EXPIRES 29. SPECIAL 30. RETIREMENT DATA 31. SEPARATION 32. CORRECTION /CARCELLATION DATA 33. SECURITY REFERER: = DATA CODE REG. HO. ee ee Wee EOD DATA _ ENG 35. VET. PREFERENCE 36. SERV. COMP. DATE 37, LONG. COMP. DATE 38. CAREER CATEGORY x. FEGL /HEALTH INSURANCE 40. SOCIAL SECURITY NO. 0—WONE CAR /RESY CObE i-s Mf. PROV /TEMP 2—10 FT. a. PREVIOUS CIVILIAN GOVERNMENT SERVICE 43. FEDERAL TAX DATA 4, SUATE TAX DATA FORM EXECUTED NO, TAX EXEMPTIONS ne 1 —YES DATE APPROVED 0~HO PREVIOUS SERVICE 1-WO SREAK 1M SERVICE 2-—GREAK IM SERVICE (LESS THAN 3 YEARS) J—GREAK I SERVICE (MORE THAW 3 YEARS) 43. POSITION CONTROL CERTITICATION 2—HO Background Use Only Do Not Reproduce FORM (4) 3-67 1152 use previous Eoimion SECRET excuoes aoe eauarie cownGRADING AND DECLASSIFICATION
14-00000 ae 1 RESIGN EFFECTIVE SECRET (When Filled In) EMPLOYEE NOTICE OF RESIGNATION FOR THE FOLLOWING REASON: dAY 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) leems 1 thru 7 and _ Items 9 thru 184 Item 5 = Item 9 = Bz re Items 11 and 15 — Item 18b — The initiating office should fill in each of the referenced items. Items 3 thru 7 and 9 thru 18 require information which pertains only to the action requested, and NOT to the current _status of the employee unless specific items remain unchanged. “Category of Employment” should show one of the following entries: Regular Summer WAE Part Time Detail Out Consultant Temporary Detail In Military Temporary-Part Time “Organizational Designations” should show ail levels of organization pertinent to identify- ing the location of the position: [Maier Component (Director, Deputy Director, etc.) Office, Major Staff, etc. Foreign Field or U.S. Field (if pertinent) Division or Staff (subordinate to first line) Branch Section Unie “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. 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 Finance, one copy only will be sent to the Office(s) concerned. SECRET