PERSONNEL ACTION
To request or record personnel actions for or by Soldiers in accordance with DA PAM 600-8.
Identification Card
Identification Tags
Separate Rations
Leave - Excess/Advance/Outside CONUS
Change of Name/SSN/DOB
DATA REQUIRED BY THE PRIVACY ACT OF 1974
SECTION I - PERSONAL IDENTIFICATION
SECTION V - CERTIFICATION/APPROVAL/DISAPPROVAL
7. The above Soldier's duty status is changed from
to
effective hours,
SECTION III - REQUEST FOR PERSONNEL ACTION
IS APPROVEDRECOMMEND APPROVAL IS DISAPPROVEDRECOMMEND DISAPPROVAL
SUPERSEDES DA FORM 4187, JAN 2000
AND REPLACES DA FORM 4187-1-R, APR 1995
DA FORM 4187, MAY 2014
HAS BEEN VERIFIED
AUTHORITY:
PRINCIPAL PURPOSE:
DISCLOSURE:
Title 10, USC, Section 3013, E.O. 9397 (SSN), as amended
ROUTINE USES:
The DoD Blanket Routine Uses that appear at the beginning of the Army's compilation of systems of records may
apply to this system.
5. GRADE OR RANK/PMOS/AOC 6. SOCIAL SECURITY NUMBER
Special Forces Training/Assignment
Retesting in Army Personnel Tests
Reassignment Married Army Couples
Reclassification
Officer Candidate School
Asgmt of Pers with Exceptional Family Members
ROTC or Reserve Component Duty
Volunteering For Oversea Service
Ranger Training
Reassignment Extreme Family Problems
Airborne Training
12. COMMANDER/AUTHORIZED REPRESENTATIVE 13. SIGNATURE
For use of this form, see PAM 600-8; the proponent agency is DCS, G-1.
11. I certify that the duty status change (Section II) or that the request for personnel action (Section III) contained herein -
SECTION II - DUTY STATUS CHANGE (AR 600-8-6)
SECTION IV - REMARKS (Applies to Sections II, III, and V) (Continue on separate sheet)
8. I request the following action: (Check as appropriate)
4. NAME (Last, First, MI)
2. TO (Include ZIP Code)
3. FROM (Include ZIP Code)
1. THRU (Include ZIP Code)
On-the-Job Training (Enl only)
Service School (Enl only)
Exchange Reassignment (Enl only)
Other (Specify)
9. SIGNATURE OF SOLDIER (When required) 10. DATE (YYYYMMDD)
14. DATE (YYYYMMDD)
Voluntary; however failure to provide Social Security Number may result in a delay or error in processing the
request for personnel action.
APD LC v1.03ES
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Fort Bragg Testing Center
Bldg 1-3571, Wing H
4520 Knox Street (Knox & Randolph St)
Fort Bragg, NC 28310-5000
Your Commander
Unit/Battalion Address
Unit or Command Rep Phone Number
......THIS IS AN EXAMPLE...............................
..............THIS IS AN EXAMPLE......................
...........EXAMPLE FOR DEFENSE LANGUAGE PROFICIENT TEST (DLPT) AUTHORIZATION...............................
1. Servicemember (SM) is authorized to take the DLPT.
2. SM has not taken the DLPT in the last 181 days.
NOTE: ....... If SM has tested within the last 181 days, SM must provide 10-14 days prior to Test Center a command approved
request for an Exception to Policy (ETP) to retest. All ETP request meeting regulatory requirements are forwarded to HRC, Army
Personnel Testing, Fort Knox to decide (dis)approval. Prior test date and score must be included on the retest request memo. (See
Test Center for ETP Example)
............................................EXAMPLE FOR INFORMATION ONLY. NOT FOR USE AS AN ORIGINAL....................................
Commander or CMD Rep w/ Assumption Orders
LONG.TERRY.EALIE.1068
908937
Digitally signed by LONG.TERRY.EALIE.1068908937
DN: c=US, o=U.S. Government, ou=DoD, ou=PKI, ou=USA,
cn=LONG.TERRY.EALIE.1068908937
Date: 2016.11.02 17:00:33 -04'00'
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