From: Name, Last Four SSN/Rate

current date

From: Name, last four SSN/rate To: Chief of Naval Operations (N134) Via: Commanding Officer, Command Name

Subj: REQUEST TO PARTICIPATE IN THE CAREER INTERMISSION PILOT PROGRAM

Ref: (a) OPNAVINST 1330.2A

Encl: (1) Enlisted Evaluations/Officer Fitness Reports (2) Personal Statement (3) Commanding Officer endorsement

1. Respectfully request to participate in the Navy Career Intermission Pilot Program.

2. In accordance with Ref (a), the following information is provided:

a. Date of birth: ; place of birth:

b. Designator and/or Rating:

c. Contact information (full name, email address, phone number, and mailing address)

d. OFFICERS ONLY: Source of commissioning and date of rank:

e. Current PRD and end date on any existing OBLISERV:

f. Achievement date of warfare and/or other significant

qualifications to include NEC codes:

g. Length of program participation requested and desired program start date, of other than PRD:

Name and Signature