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'---\!i '..' .. ,,i- i' \ i '-." "cAUi rolrr Nor ro BE usED FoR i THrs rs AN tMpoRTANT REcoRD. { ) ANy ALTERATToNs rN sHADED AREASIDENTIFICATION PURPOSES RENDER FORM
CERTIFIGATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTY
, 1,. NAME,fLasf, First,. Middle) . ..
DAVIS, .:.'ANDRE. DEVONdAE :
2. DEPARTMENT, COMPONENT AND BRANCH
ARMY,/USAR
:3:.,,,SOGlAl
::i:i:.4i2,9,i,::rl:i
sEcuRlfr.:'.',.,,, itll:: ::
5..DATE OF B|RTH (YYYYMMDD)
r-985032r-6. RESERVE OBLIGATION TERMINATION DATE
(YYYYMMDD) 201103107a. PLACE OF ENTRY INTO ACTIVE DUTY
MTIJI'INGTON, TENNESSEE
b. HOME OF RECORD A TIME OF ENTRY
236 WTIJSON CIRCI'EHAYNES ARI(ANSAS 7234]--OOOO
(Clty and state, or complete address if known)
8a. LAST DUTY ASSIGNMENT AND MAJOR COMMAND
O467ENCO A CMBT AR FC
b, STATION WHERE SEPARATED
FORT BENNING, GA 3].905-50109, COMMAND TO WHICH TRANSFERRED
SEE BLOCK 1-8
'ro. sGLr covERAGE I INoNEAMOUNT: $ 250,000.00
11. PRIMARY SPECIALTY (List number, tltle and years and months in 12. RECORD OF SERVICE YEAR(S) MONTH(S) DAY(s)
one or more years.)
21810 COMBAT ENGTNEER - r- YRS 2 MOS/INOTHTNGFOITLOWS \
a. DATE ENTERED AO THIS PERIOD 1. :i, Ar
b. SEPARATION DATE THIS PERIOD :;f*P:$f;jliil
.'i:Ut.i:r.r.ic. NET ACTIVE sERvlCE THIS PERIoD tii$l ri!2isii:r rii
d. TOTAL FRIOR ACTIVE SERVICE l: AFF,...:: ilBIiO.CIS. :*i;i;a#+,8,i*i
s. TOTAL PRIOR INACTIVE SERVICE lrii:rg:Eli:,li:{ I i:1,, E$b.ci<i iii;.:'+liCi:lririi
f. FOREIGN SERVICE :,..;:0'.0.0,0i :,.':j,:,r,,,0 e,i:,'i::l
g. SEA SERVICE :.::1]:0,0',iri .r I, ,'.00,, .,
h. EFFECTIVE DATE OF PAY GRADE ::!2:A,A:4:..I3.
DECORATIONS, MEDALS, BADGES, CIT.A,TIONS AND CAMPAIGNRIBBONS AWARDED OR AUTHORIZED (Ail p.eriods of service)
NATIONAIJ DEFENSE SERVICE MEDAL//ARMY SERVICER]BBON//ARMED FORCES RTSERVE MEDAIJ W/ Iq,DF.VICE/ / GLOBA], WAR ON TERRORISM EXPEDITIONARYMEDAI,/ /GLOBAL WAR ON TERRORTSM SERVICE MEDALL//IRAO CAMPAIGN MEDAI],//NOTH]NG FOLI.OWd
14. MILITARY EDUGATION (Course title, number of weeks, and month andyear complated)
NONE/,/NOTHING FOIJLOWS
{5a. MEMBER CONTRIBUTED TO.POST-VIETNAM ERA VETERANS, EDUCATIONAL ASSISTANCE PROGRAMb. HIGH SCHOOL GRADUATE.OR EQUIVALENT
YES
YES
X NO
NO
I6. DAYS ACCRUED LEAVEP.A|D 0
17. MEMBER WAS PROVIDED'COMPLETE DENTAL EXAMiNATION AND ALL APPROFRIATEDENTAL SERVICES AND TREATMENT WITHIN 90 DAYS PRIOR TO SEPARATION
YES NO
X
jFQL,LOWS
sSPAIATION (lnclude ZlF.Code)
:l'i ,i::, :' ;::,iiti
.:,':,':il :il ,,';.l ti.i:t:it,
' , lti tl;: r ' ii !:: ;::,!,: :lij i ::';
20:, MEMBER;,REQUE llliili,r::::..4R'r ir r,':':,:r,iii:r, :,:,:t,, :,,l:DIRECf,OR OF,VEIERANS::AFFAIRS., lX,r;r;liiiYESrt rNo
.:21r:1,::SIGNATURE 22t
iT,IMOTHY
VOID
SPECIAL ADDITIONAL INFORMATION (For use by authorized agencles only)
23. ryPE OF SEPARATION
REIJEASE FROM ACTIVE DUTY25, SEPARATION AUTHORITY
AR 635-200,CHAP 4
c (lnclude upgndes)
27.
NA
IIONORABI,E
LBK
RiT..ICTRY CODE
28. NARRATIVE REASON FOR SEPARATION
COMPI,ETTON OF REOUTRED ACTIVE SERV]CE29, DATES OF TIME LOST DURING THIS PERIOD (YYYYMMDD)
NONE
30, MEMBER REQUESTS COPY 4(lnitials)
2000 SERVICE.2
Ii
L-
