PRIVACY ACT STATEMENT

AUTHORITY: Title 5, U.S.C.

PRINCIPAL PURPOSE: To request and obtain individual berthing.

ROUTINE USES: Information used for supply and fiscal accounting and may be used to substantiate berthing provided.   Failure to provide the information will result in contract berthing being denied.
 

1.      NAME (Last, First, MI)

2.      RANK/RATE

3.  SEX
M     F

3.      LAST 4/SSN
 

4.      REQUESTED DATE(S)
Check in Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 2009 2010 2011    Check out Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 2009 2010 2011

 
5.      UNIT ASSIGNED 

  Choose a Unit CBMU 303 DET B NCHB 14 FUEL A PHIBCB 1 DET 102 ESU DET 51B OPS SUPP 1939 NSF NWSSB Corona Det. NMCB 17 DET 1517 SURGEMAIN MORVL NWSSB FALLBROOK EOT 1 NFELC SURGE DET A NR OHSU DET D

Choose your Place of Berthing: Choose One Fallbrook Moreno Valley Port Hueneme San Diego

6.      ADDRESS
                  Street   

City:       Choose State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip Code:
 

 
8.  PHONE

Home Number including area code: (xxx-xxx-xxxx)

Work Number including area code: (xxx-xxx-xxxx)

Cell Number including area code: (xxx-xxx-xxxx)
 

 9.  Personal Remarks

10. I certify that I reside outside a 50 mile radius from my drill site or have a waiver approved by the Readiness Commander/Commanding Officer. In addition, I will perform at least eight hours (2 drills) the day following berthing provided, or four four-hour drills within a 48 hour period. I understand that if a berthing reservation is made, and I am subsequently found ineligible, i.e. not meeting NAVRESREDCOMREGNINETEENINST 11103.1 requirements, I will be liable for reimbursing the Navy for the cost of the contracted room. If berthing is contracted and not used, the second Ano-show offense will result in a temporary loss of my berthing privilege, as will non-payment. PRIVACY ACT STATEMENT AUTHORITY: Title 5, U.S.C. PRINCIPAL PURPOSE: To request and obtain individual berthing. ROUTINE USES: Information used for supply and fiscal accounting and may be used to substantiate berthing provided. Failure to provide the information will result in contract berthing being denied. REDCOM SOUTHWEST 11103/1 (1-95)  
 

 
11.    Electronic Signature (Type full name or initials)

 
12.  Date  (will be noted on submission)

Your Email:

Note:  This form must be completed and returned to the supply/Logistics Officer the month prior to the drill.  In the event that a reservation must be cancelled, you must notify the Supply/Logistics Office by Wednesday noon prior to the drill.