FORM KP1-16B Rev 11/10

UNITED STATES MERCHANT MARINE ACADEMY MIDSHIPMAN LIBERTY REQUEST

ROOM: ____________ DATE: _____________

PART A GENERAL INFORMATION (REQUIRED FOR ALL LIBERTY REQUESTS) 1. NAME OF MIDSHIPMAN REQUESTING LIBERTY: 2. CLASS: REQUESTED PERIOD OF LIBERTY: 4a. FROM (DATE/TIME):

3. COMPANY:

4b. TO (DATE/TIME):

5. TYPE OF LIBERTY REQUEST: CONSULT THE MISHIPMAN REGULATIONS AND LONG WEEKEND (FRI-SUN) SPECIAL LIBERTY COMMANDANTS NOTICES FOR SPECIFIC POLICY CONCERNING REGULAR LIBERTY, SPECIAL LIBERTY, SHORT WEEKEND (SAT-SUN) EMERGENCY LEAVE EMERGENCY LEAVE, CLASS RATES, ETC. DINNER LIBERTY 6a. ADDRESS DURING LEAVE PERIOD: 6b. CONTACT PHONE DURING LEAVE PERIOD: HOME OTHER: __________________________________________ 7. CERTIFICATION AND SIGNATURE: I CERTIFY THAT I HAVE NO WATCHES, EXTRA DUTY, OR OTHER OBLIGATIONS DURING THIS PERIOD AND UNDERSTAND THE LEAVE AND LIBERTY POLICIES THAT APPLY TO ME SIGNATURE: ________________________________________________________ PART B FACULTY AND DEAN CONCURRANCE (REQUIRED ONLY WHEN CLASSES ARE TO BE MISSED) 8. CLASS/COURSE NAME: 9. CONCUR/NON-CONCUR: 10. REASON FOR NON-CONCUR:

11. FACULTY SIGNATURE:

CONCUR CONCUR CONCUR CONCUR CONCUR CONCUR

NON-CONCUR NON-CONCUR NON-CONCUR NON-CONCUR NON-CONCUR NON-CONCUR

12. DEAN/ASSISTANT DEAN RECOMMENDATION: APPROVE DISAPPROVE SIGNATURE: ________________________________________________________ PART C APPROVAL (REQUIRED FOR ALL LIBERTY REQUESTS) 13. COMPANY COMMANDER: APPROVE DISAPPROVE SIGNATURE: ________________________________________________________ 14. BATTALION COMMANDER: APPROVE DISAPPROVE SIGNATURE: ________________________________________________________ 15. COMPANY OFFICER: APPROVE DISAPPROVE SIGNATURE: ________________________________________________________ PART D MOD ACTION (MUST BE COMPLETED BY MOD PRIOR TO DEPARTURE AND UPON RETURN) 16. DATE/TIME: 17. PROPER LIBERTY ATTIRE: 18. MOD NAME: 19. MOD SIGNATURE: OUT YES NO

YES NO PART E REQUEST STATEMENT OR SPECIAL INSTRUCTIONS (ATTACH ADDITIONAL SHEETS IF NECESSARY) 20. MIDSHIPMAN SHALL PROVIDE BRIEF EXPLANATION; CO SHALL NOTE ANY RETRICTIONS OR SPECIAL REQUIREMENTS:
IN