FLEET RESERVE / RETIREMENT APPLICATION
Name: _________________________ Rank/Rate: _______ SSN: ________________ Date: __________
ADSD: __________ Div: __________ Work Phone: ________________ Home Phone: __________________
Circle / Indicate Yes or No below:
1) RETIREMENT PHYSICAL COMMENCED? Y / N Report Date (YY MM DD): _________________
2) CONTACT RELIEF REQUIRED? Y/N HYT Date (YY MM DD): ___________________
3) RETIREMENT DATE REQUESTED: ______/______/_____ (Must be the end of the month)
4) CANCEL PREVIOUS REQUEST? Y/N If answer is NO, skip question 5
5) REASON: __________________________________________________________
6) USNR? Y/N
7) OBLIGATED SERVICE NEEDED? Y/N Current EAOS (YY MM DD): ________________
8) IS MEMBER FULL TIME SUPPORT (FTS)? Y / N
9) MAT WAIVER REQUIRED? Y/N
10) PRD ADJUSTMENT REQUIRED? Y/N Current PRD (YY MM): ____________________
11) ADJ PRD TO WHAT YR/MO: YR _____ MO _____ (Must be the same date as FLTRES Date)
12) PRIOR MILITARY SERVICE? Y/N Date: _________________ Branch: _______
_________
13) REQUESTING HEROISM BENEFITS: Y/N
14) # DAYS TERMINAL LEAVE REQUESTED __________________ Leave Date (YY MM DD): __________________
15) DAYS OF PDTY REQUESTED __________________ (House Hunting & Job Hunting, max: 20 Days)
16) FURTHER REMARKS: __________________________________________________________
17) RETIREMENT CEREMONY*: Y / N (Member must initial:______), If NO, spouse was informed.
(*If NO, skip block 18 & 19. If Yes or tentative or not sure if ceremony is desired, MUST fillout blocks 18 & 19)
18) SPONSOR (Will Coordinate Ceremony) Rate / Name: ______________________________ Phone: ____________
19) LOCATION & DATE OF CEREMONY: ________________________________________________________
20) COMMENTS (Reason for not having a ceremony, and other remarks): _____________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
21) CO’s RECOMMENDATION Y/N
The authority to request this information is contained in 5 USC 301, departmental regulations. The principal purpose of the information is to enable you to make known desire for transfer to fleet
reserve. The information will be used to assist officials and employees of the Department of the Navy in determining your eligibility for and approving or disapproving your request for fleet reserve.
Completion of this form is voluntary. However failure to provide the request information may impact your approval. All information above are correct.
Date: _________________ Member's Signature: ________________________________
Page 1 of 2 Navy Career Wise FLEET RESERVE FORM 1160/3 (9/07 )

FLEET RESERVE / RETIREMENT APPLICATION
PRELIMINARY ROUTING (Sign & Date. Fill out remarks block for further comments)
(REQUESTING MEMBER MUST PERSONALLY OBTAIN SIGNATURES)
* PRT COORDINATOR _____________________________________DATE:_____
* DAPA: ________________________________________ DATE:_________
* LEGAL (No Pending Issues): ________________________________________ DATE:_________
* SEPARATIONS CLERK (Personnel): ________________________________________ DATE:_________
* ADMIN ASST (Retirement Clerk): ________________________________________ DATE:_________
* DIVISION CAREER COUNSELOR: ________________________________________ DATE:_________
Check list verified by Division CC: ____ Verify ADSD: Must complete 20+ Years of Service by FLTRES date
Check list verified by Retirement Sponsor: ____ Received Retirement Ceremony Checklist (Coordinate with Admin)
Further Remarks:
* MUST VERIFY SPECIFIC INFORMATION ON FRONT OF REQUEST
APPROVAL ROUTING
RETIREMENT SPONSOR: ____________________ DATE:___________ YES:______ NO:______
SHOP/DIV LCPO: ____________________ DATE:___________ YES:______ NO:______
DIV/DEPT LCPO: ____________________ DATE:___________ YES:______ NO:______
DIVISION OFFICER: ____________________ DATE:___________ YES:______ NO:______
DEPARTMENT HEAD: ____________________ DATE:___________ YES:______ NO:______
CCC: ____________________ DATE:___________ YES:______ NO:______
FINAL APPROVAL
CMC: ____________________ DATE:___________ YES:______ NO:______
ADMIN OFFICER: ____________________ DATE:___________ YES:______ NO:______
EXECUTIVE OFFICER: ____________________ DATE:___________ YES:______ NO:______
EXECUTIVE DEPUTY: ____________________ DATE:___________ YES:______ NO:______
COMMANDING OFFICER: ____________________ DATE:___________ YES:______ NO:______
CO REMARKS / COMMENTS:
REASON FOR DISAPPROVAL (CO USE
ONLY):
Page 2 of 2 Navy Career Wise FLEET RESERVE FORM 1160/3 (9/07 )