SPECIAL REQUEST/AUTHORIZATION Liberty Phase: 3

NAVPERS 1336/3 (Rev. 9-75) GPA: N/A

S/N 0106-LF-063-8633 Brks: 1664 Room: 214

PRIVACY ACT STATEMENT

The authority to request this information is contained in 5 USC 301, Departmental regulations. The principle purpose
of the information is to enable you to make known your desire for one of the four items listed or for some other special
consideration or authorization. The information will be used to assist officials and employees of the Department of the
Navy in determining your eligibility for and approving or disapproving the special consideration or authorization being
requested. Completion of the form is mandatory; failure to provide the required information may result in delay in
response to or disapproval of your request.
NAME (Last, First, Middle Initial) RATE SSN

Snider, William E1 XXX-XX-1371

SHIP OR STATION DATE OF REQUEST

MAGTF TC, 29 Palms, CA 92278 20101208

DEPARTMENT/DIVISION/WARD DUTY SECTION/GROUP

Bravo Company, MCCES DSTC 12-11

NATURE OF REQUEST

SPECIAL SPECIAL COMMUTED OTHER

LEAVE
REQUEST PAY RATIONS (Below)
NO. DAYS REQUEST FROM (Date and time) TO (Date and time)

3 20110114 @ 1630 20110117 @ 2200

DISTANCE (Miles) MODE OF TRAVEL

225 Miles AIR TRAIN BUS CAR

LEAVE ADDRESS (Street, Box or route no., City, State, Zip Code) TELEPHONE NUMBER

18437n 111th Dr Surprise

Phoenix, Az 85374 513-546-4937
REASON FOR REQUEST

Visit Friends
SIGNATURE OF APPLICANT

I AM ELIGIBLE AND OBLIGATE MYSELF TO PERFORM ALL DUTIES OF PERSON MAKING APPLICATION - DUTY STATION
SIGNATURE OF STANDBY (PRINT AND SIGN LEGIBLY)

PERSONNEL OFFICE
EARNED LEAVE LEAVE THIS FISCAL YEAR DATE LAST PAID

DAYS AS OF
RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO       SSgt Course Coordinator      

RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO - - - -
RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO - - - -
RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO - - - -
RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO - - - -
RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO - - - -
RECOMMENDED APPROVAL SIGNATURE AND RANK/RATE/TITLE/DATE

YES NO - - - -
REASON FOR DISAPPROVAL

     
LOG OUT AND IN WITH OOD (When required)
OUT (Hour and date) INITIALS OOD IN (Hour and date) INITIALS OOD
      @                  @           
HITCHHIKING IS PROHIBITED
 Marine Corps Communication and Electronics School
Holiday/Leave Accident Reduction Program

The Safety Officer Marine Corps Communication and Electronics School, has established the Holiday/Leave Accident Reduction
Program (HARP), in an effort to reduce the off-duty incidents/mishaps. Leaders at all levels have a moral obligation to take care
of the Marines under their charge. All MCCES personnel are highly encouraged to complete this form prior to the start of any
extended liberty, Holiday, Annual or Emergency Leave periods. This form is intended to be a decision-making and counseling
tool for supervisors of all levels and will facilitate a more proactive approach to safety.

DATE: 20101208
PART A: PERSONAL INFORMATION (To be filled out by individual Marine)
NAME: Snider, William RANK: Pvt AGE: 19 CO/SECT: B Co. DTS 12-11
PERIOD COVERED: 20110114 - 20110117 OCCASION: LV SPEC LIB 72 96 PCS
SNCOIC NAME/RANK: MSgt McIntire OIC: Capt Toal
DESTINATION: California, L.A.
MODE OF TRAVEL: Taxi Cab If POV, are you driving alone? NO

PART B: SMALL UNIT LEADER QUESTIONS (Fill out while counseling SNM in Part A)
1. Transportation Plan: (Identify potential hazard and develop controls to mitigate risk).
Potential Hazards Developed Controls
Taxi gets in a accident Always Wear Seat Belt
Taxi Breaks Down Driver is able to call for another Taxi or Phone for another taxi
traffic always leave early
blown tire check for spare and tools to change tire
get robbed cancel bank card
           
           
           
           
2. Activities: (Identify potential hazards, develop controls and identify PPE to mitigate risk).
Potential Hazards Developed Controls
Avoid dangerous or high risk situatuions,be aware of my surroundings, always carry a cell
personal injury
phone
drugs or alcohol Avoid them
social conflict call the police
sunburn wear sun screen
phone #s have Bravo Co. number in case of emergencies.
           
           
           
           
3. USMC policy on drugs/alcohol, off limit areas. Are you aware of all rules and regulations? YES
4. Do you understand how to apply ORM to reduce your risk of injury? YES
5. Vehicle Inspection Completed: N/A (ONLY N/A IF YOU ARE NOT USING YOUR POV)
NOTE: SMALL UNIT LEADERS WILL INSURE THEIR MARINES KNOW HOW THEY MAY GET IN
CONTACT WITH THEM IF THEIR PLANS CHANGE OR THEY NEED ASSISTANCE.
Supervisor Signature: Date:
           
Marine’s Signature: Date:
           
 TRAVEL ITINERARY
CASE OF: LCpl Long, Aaron J

Date Arr. Location Dep. Means of

Time Time Transportation
20101210      29 Palms, CA 1630 car
20101210 2000 Phoenix, AZ      car
                           
                           
20101212      Phoenix, AZ 1600 car
20101212 2000 29 Palms, CA           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           
                           

Points of Contact:
Name of Individual Phone # Relationship Verify
Tiffney Long 602-909-9609 Brother
Sandra Long 602-909-5975 Brothers Wife
                 
                 
                 
                 

Destination(s) Information:
Name of Place Phone # Address Verify
18437n 111th Dr Surprise
Phoenix, AZ 602-909-9609
Phoenix, Az 85374
                 
                 

Additional Comments:
(How are you getting TO AND FROM your destination? Who is picking you up? How are they picking you up (i.e.
Mom's Car)? Who are you going with? Etc.)
I will leave here 29 Palms at 1630 or whenever we are let loose and arrive at 2000 in Phoenix Arizona. I will leave
at 1600 and will be back in time for curfew 2200. My transportaion will be provided by a friend from Phx

All Out-of-Bounds, PTAD, and Leave Requests must have the following:
• Request (NAVPERS 1336/3)
• PAD letter from recruiter (Recruiters Assistance only)
• Travel Itinerary (above)
• Proof of transportation (If commercial transportation is used)

• Map showing origin and destination (mapquest.com, driving directions)