<p> current date </p><p>From: Name, last four SSN/rate To: Chief of Naval Operations (N134) Via: Commanding Officer, Command Name</p><p>Subj: REQUEST TO PARTICIPATE IN THE CAREER INTERMISSION PILOT PROGRAM</p><p>Ref: (a) OPNAVINST 1330.2A</p><p>Encl: (1) Enlisted Evaluations/Officer Fitness Reports (2) Personal Statement (3) Commanding Officer endorsement</p><p>1. Respectfully request to participate in the Navy Career Intermission Pilot Program.</p><p>2. In accordance with Ref (a), the following information is provided:</p><p> a. Date of birth: ; place of birth:</p><p> b. Designator and/or Rating:</p><p> c. Contact information (full name, email address, phone number, and mailing address)</p><p> d. OFFICERS ONLY: Source of commissioning and date of rank:</p><p> e. Current PRD and end date on any existing OBLISERV:</p><p> f. Achievement date of warfare and/or other significant </p><p> qualifications to include NEC codes:</p><p> g. Length of program participation requested and desired program start date, of other than PRD: </p><p>Name and Signature</p>