(ow-ot23-10286) | SECRET | 2 tp PS ¢ (When Filied In) - . DATE PREPARED 23 May 19 REQUEST-FOR PERSONNEL ACTION + NAME (Last-First-widdle) CCOSEELL, Jame Po dre + NATURE OF PERSONNEL ACTION 4. EFF ECTEVE DATE REQUESTED] $3. CATEGORY oF EMPLOYMENT 7. COST CENTER NO. CHARGE- - LEGAL AUTHORITY (Completed by Office of Personne!) » ORGANIZATIONAL DESIGNATIONS t/t 3-26 Mieinistrative Section Security Unit 2. POSITION TITLE 12. POSITION NUMBER Security Officer &S 14. CLASSIFICATION SCHEDULE (GS, LB, ete.) . 17. SALARY OR RATE as 2610.02 . 14,350 18. REMARKS 1 JUN iSoz ees eeaeese From: 0S/08/DD Invest-Qper Sup/ss Dtv/oc/osfO = Security Approval has been gudaled fo the use contemplated by this request 259s exdbeitte’ to Steff lus. G. © “eee” Subject to depart. e/a & Zune 196e 2 ief Personnel Security DivisioniC coal 184. SIGNATURE OF REQUESTING OFFICIAL DATE SIGNED 168. SEGNATURE OF CAREER SERVICE APPROVING [DATE SIGNED OFFICER SPACE BELOW FOR EXCLUSIVE USE OF THE OFFICE OF. PERSONNEL 13. ACTION [20 EMPLOY.(21. OFFICE CODING 22 STATION 23. BTEGIEE | 2%, MODTRS J 25. DATE OF BIRTH 26. DATE OF GRADE 27, DAYE OF LEE . COOE COOE CODE GOSe ; NUMERIC | ALPHABETIC 26.NTE EXPIRES 29, SPECIAL 30. RETIREMERT GATA 31, SEPARATION] 32. CORRECTION/CANCELLATION DATA 33, SECURITY _ Ea —_ REQ. BO. 5, VET. PREFERERCE [36.SERV. COMP. DATE (37. LONG, COMP. DATE | 38 MIL. SERY CREDIT/LCD | 39. FEGLI / HEALTH INSURANCE 40. SOCIAL SECURITY RO, . . D = KONE 690. Oa, vr. ~ 5 pr, # 10 er, a1. PREVIOUS GOVERNMENT SERVICE DATA P2. LEAVE CAT, | %3. FEDERAL Tae DATA ae, STATE TAR GATA cone : 0, Tax EXEMPTIONS foRM EXECUTED lo. ves (OO = MO PREVIOUS SERVICE io #0 BREAR im SERVICE 2 » BREAK tm SeRvice {LESS Haw 12 mos 3 «© BREAK we Senvice (moRE YHaw 12 sos 2 = ¥O 43. POSITION CONTROL CERTIFICATION 4@. G.P. APPROVAL DATE APPROVED FORM 8.63 {152 use ereveous contion. SECRET (4)
(Bhen Filled In) i EMPLOYEE NOTICE OF RESIGNATION Sten grt tera tg P< RESIGN EFFECTIVE FOR THE FOLLOWING REASON: MY LAST WORKING DAY WILL BE - DATE SIGNED SUGNATURE OF EMPLOYEE FORWARD COMMUNICATIONS. INCLUDING SALARY CHECKS AND BONDS. TO THE FOLLOWING ADDRESS (Number, Street, City, zone, State) | INSTRUCTIONS Items 1 thru 7 The initiating office should fill in each of the referenced items. and - Items 3 thru 7 and 9 thru 18 require information which pertains only Items 9 thru 18a to the action requested, and NOT to the current status of the! ‘hi? ployee unless specific items remain unchanged, item 5 ~ “Category of Employment” should show one of the following entrigs: Regular Summer WAE ° seeee Part Time Detail Out Consultant eee Temporary Detail In “Military , --- eee Temporary - Part Time . "es Item 9 - "Organizational Designations" should show all levels of organization pertinent to identifying the location of the position: ass = z|Major Component (Director, Deputy Director, etc.) teens 2-4 Office, Major Staff, etc. ° Division or Staff (subordinate to first line) ate Branch . * Section Unit Item 11 - "Position Title" should reflect the standard abbreviated title given , in the most current edition of the Position Control Register or re- ported on Form 261, Staffing Complement Change Authorization. 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 Service should approve and the other Career Service should concur in Item 1 » 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 Office(s) concerned. SECRET