1. I CaUITON NOT IO aE USED FOr
i IDENIIFICATION PURPOSES
THIS IS AN IMPORTANT RECORD
SAFECUARD tT
ANY ALIERATIONS IN SHADED
AREAS RENOER FORM VOID
Illl :3t|, 214
PREVIOUS EDI]IONS OF IHIS
FORM ARE OBSOtEIE,
CERIIFICATE OF RETEASE OR DISCHARGE
FROM ACTIVE DUTY
S$&ffii"ff&lfif;rd a.o{rgp
2, D;?ARIMENT, COMPONENI AND SRANCH
Xer:r - ttsI
i
3. 50CrA( StCURtIY NO
. 265
t 8?
t 6049
.a.fdaDE. tAr€ oR RANX 4b. PAY GRADE
E-5
5, DAIE OF BIRT!"I
r 1 JUL ti5
6 Pl'ACE OF ENIRY INTO ACTIVE DUTY
Jrcrg0e,t&LE, FL
7. L,A5I DUIY ASSIGNMENT ANO MAJOR COMMAND
itt$ E08EE CS-30, Saa O1e6o, CI
8. STAIION WHERE SEPARAIED
lJ88 SEXE C6-J0, Saa D1ago, Cl
CEXTEB HEI 0illg.if,"*S Il ?01{9
9. COMMANO TO WHICH IRANSFERRED
ti.tYtl, flr.sEnYE Pr-&Si]flSEL
)0 SGUCOVERaGE
-^
AMouNr, il, ooo [-l"o*
I I, PRIMARY SPECIATTY NUMEER, II]LE AND YEATS AND
MoNIHS rN spEClAtTy (Addilioflal specinlty numbers and titlcs
inuoluing period.s ol one or more years)
rc-1 163
5P0-558 FLre ilrratrol E&dsr
Techn; clen x
I
.t
I
I 2, R€CORD OF SERVICE YEAR fs) MON TS' oav (s,)
a. Dotc Enlered AD Ihlr Pc.lod o5 Ufj{t u(
b. Seoorotlon Dote Thl! P6rtod 9i9 lrglr rre
c. N.l Aclivo Sgrvi<. Ihl! Poriod rr? 1t1' itt
d, Iotol P'io. Actlve SerYr(o YI' v*, UU
e, lolol Prior lno(llYe 5.rYI(6 I,e tt urJ
l. Foreign Ser"ice tt tE, EO
8. Seo Seti< !t{ II t,
h. Elleclivc Dolo ol Poy G.od6 at BET le
l. Rcrc,re Obliq. Iarm. Dote o, uts; rJo
r3.IEElXPNSREDIE[bllili cEpfdfuf E&tlfwARDEDoRaurloRrzED (Attperiods,,lseiibel .
fea scrrlec Doplofurat'-r1bborl-r'rum[-6ooc oondu6lt for p*rlod Edleg 06 DEC$gr
IXIXIIIIIITIII
II, IIIIXIXIIXI,X
ld. MILIIARY EDUCAIIoN (Course Titb, qumber weehs, and, month anil year ciompletedl
BeeE scor, 10 reclcr, lpr 8{1 Flra codtrslr'Tabalclan clacg
&4, SfO-55,5 CSF, e6FB t-lgt-$tg?, 3S ro.kr, Oat 65r
iA' S€hool, a6 Ha€*a, Iov
I5. MEMSER CONIRIBUIEO IO POSI.VIEINAM ERA
VEIERANS' EDUCA!IONAI, ASSISIANCE PROGRAM
NO
tr
YES
g
'I6, I-]IGH SCHOOI. GRAOUAIE OR EOUIVAI,ENI
Fl ,r, fl "o
I 7. DAYS ACCRUED
I.EAVE PAID
I8. REMARKS
rtedleal Bnd Btatal Trrortroat Cagletedt
DISTID$trffi or Do al{ Ilr [rgtrIl.ptft]soilIrff 1900. t
TIII
IIII
t
I
x
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x,
I
I
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X
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'"$!.BUlM6*&flArA,oN
Pqffi &rrc8, rL 3est,
20. ME}'BER REQUESIS COPI 6 BE
SENI IO DN. OF VEI
aFF^rRs- l--lr* I-f *o
22. wPED NAME, GtaDE, rmtan6 sloxrrure or oirrffi
AUIHORTZEOTOSTCX &t- .fJ-J*{.d-,p
t g $Ptrr68&, rcg, ,ffi- gr BxxBrIfi
SPECIAT AOD'NONAL rnaF()ltlltqN (Foruu O! a$Iertd o^a)
23. IYPE oF sEpArAIoN BAlm*A ftre letltllr
dnty rnd tmacfor to f,avrI f,sssrre
24. CHARACIETOF *gvtcE (h*tfu ,tpgtda)
EOTO*TEI.E
25. sEPAFAIION AUIHORTTY
xlltE58ilfi 1680t60
2'. sEPATAIION COOC
ff
17. lEr{usilffENlcoDE
ln-Ii
ln NARTATIVE IEASON FOT SEPATAIION
&rytrattoa ol tcrr of, Eqllatrrut
29 D^IEs OF IIME I.OSI DUPING IHIS PERIOO
'tx.'+QflE.
rc'MEr'EEtWNrr
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