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SEE PRIVACY ACT STATEMENT ON REVERSE ... - United …

SECTION 1. STUDENT DATANAMESSNUNITPHONE SECURITY CLEARANCE _____GENDER ____ CIVILIAN JOB SERIES/PAY PLAN DATE OF RANKPROM PTS _____BOARD DATE (PLDC)_____GT (YY/MM/DD)(YY/MM/DD)PMOSSTAR MOS UIC _____DEROS _____ ETS _____ AUTH MTOE/TDA PARA/LNEMAIL ADDRESS (REQUIRED)STUDENT SIGNATUREBy signing this document, I acknowledge that an application has been submitted on my behalf to attend school. SECTION 2. COURSE INFORMATIONCOURSE TITLECOURSE NUMBER _____SCHOOL CODE PURPOSE/JUSTIFICATION (REQUIRED)PRIMARY CLS CLS 3. COMMAND APPROVAL FOR REQUESTCOMPANY COMMANDER CONCUR / NONCONCURDATEBATTALION COMMANDER CONCUR / NONCONCURDATEBRIGADE COMMANDER CONCUR / NONCONCURDATES3/G3 REPRESENTATIVE CONCUR / NONCONCURDATECIVILIAN SUPERVISOR CONCUR / NONCONCURDATESECTION 4. STATUS OF TRAINING REQUESTSTUDENT HAS BEEN CONFIRMED FOR COURSE DATESSTUDENT HAS BEEN PLACED ON THE WAITING LIST FOR COURSE DATESTRAINING IS DISAPPROVED FOR THE FOLLOWING REASON(S):FORM IMPC-HAW-PLS-1 REVISED AUGUST 2011 SEE PRIVACY ACT STATEMENT ON REVERSE (YY/MM/DD)(REQUIRED FOR ASI/SQI PRODUCING COURSES) military TRAINING REQUESTThe proponent of this form is the Directorate of Plans, Training, Mobililization and SecurityPREVIOUS FORM IS OBSOLETERANK/GRADEPROFILE?

AUTHORITY: 5 U.S.C. Sections 4101-4118; and E.O. 9397. PRINCIPAL PURPOSE: To request training by military and civilian personnel and to document the authorization

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