Application Receipt Date:
Prior Review Prior Review Date:
I. Applicant Request
Request: Upgrade Reason Change RE Code Change
Issues:
II. Were Proper Discharge and Separation Authority procedures followed?
Yes No Tender Offer:
See Attachments: Legal Medical Minority Opinion Exhibits
III. Original Character of Discharge
Unit CDR Recommended Discharge: Date:
Discharge Received: Date:
Chapter: AR:
Reason:
RE: SPD:
Unit/Location:
Time Lost:
Article 15s (Charges/Dates/Punishment):
Court-Martials (Charges/Dates/Punishment):
Counseling Records Available: Yes No
IV. Soldier’s Overall Record
DOB:
Current ENL Date: Current ENL Term: Years
Current ENL Service: Yrs, Mos, Days
Total Service: Yrs, Mos, Days
Previous Discharges:
Highest Grade:
Performance Ratings Available: Yes No
MOS: GT: EDU: Overseas: Combat:
Decorations/Awards:
V. Post-Discharge Activity
Home of Record:
Current Address:
Post Service Accomplishments:
VI. Facts, Circumstances, and Legal Basis for Separation
a. Facts and Circumstances:
b. Legal Basis for Separation:
c. Response to Issues, Recommendation and Rationale:
VII. Summary of Army Discharge Review Board Hearing
Type of Hearing: Date:
Location:
Did the Applicant Testify? Yes No
Counsel:
Witnesses/Observers:
Exhibits Submitted:
VIII. Board Decision
The discharge was: Proper Improper
Equitable Inequitable
The characterization of service was: Proper Improper
Equitable Inequitable
The narrative reasons were: Equitable Inequitable
DRB voting record: Change No change (Character)
Change No change (Reason)
(Board member names available upon
request)
IX. Board Discussion, Determination, and Recommendation
Case report reviewed and verified by: , Examiner
X. Board Action Directed
No Change
Issue a new DD Form 214
Change Characterization to:
Change Reason to:
Other:
RE Code:
Grade Restoration: No Yes Grade:
XI. Certification Signature and Date
Approval Authority:
ROBERT L. HOUSE
Colonel, U.S. Army
President, Army Discharge Review Board
Official:
MARY E. SHAW DATE:
Lieutenant Colonel, U.S. Army
Chief, Secretary Recorder
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Applicant Request Request: Upgrade Reason Change RE Code Change Issues: See applicant's attached DD Form 293. Previous Discharges: USAR-860108-860123/NA ADT-860124-860509/UNC Highest Grade: E3 Performance Ratings Available: Yes No MOS: 76X10 (Subsistence Supply Specialist) GT: 86 EDU: HS Grad Overseas: None Combat: None Decorations/Awards: ASR, NDSM V. Post-Discharge Activity Home of Record: Current Address: Post Service Accomplishments: None Listed VI. Certification Signature and...
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