PASS/LIBERTY AND NO COST TDY REQUEST
(This form will be used in lieu of DA 31 Army, AF Fm 988 AF, NAVCOMPT FM 3065 Navy, DD FM 1610. Completion of this form is
mandatory, failure to provide the required information may result in your request being denied.)
NAME RANK REQUEST DATE
SERVICE/DEPT DUTY PHONE
PASS/LIBERRTY/TDY ADDRESS
PHONE ( ) -
Check number days:
2 DAY 3 DAY 4 DAY
DATES: FROM TO
SIGNATURE OF MEMBER DATE
Approved/Disapproved
SUPERVISORSʼ SIGNATURE DATE
Approved/Disapproved
ACTIVITY HEAD/DIRECTOR DATE
Approved/Disapproved
CDR SIGNATURE DATE
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PRIVACY ACT STATEMENT
AUTHORITY: Title 5 U.S.C., section 552a
PRINCIPAL PURPOSE: To authorize military pass/liberty/no cost TSY, document the start and stop of such request; record address
and telephone number where you may be contacted in case of emergency during pass/liberty/no cost TDY.
ROUTINE USES: Information may be disclosed to the Department of Justice, and to federal, state, local or foreign law enforcement
authorities for investigating or prosecuting a violation or potential violation of law. The American Red Cross for information
concerning the needs of the member or dependents and relatives in emergency situations.
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MPO Form 526 (11/98)
