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10. RECORD OF SERVICE YEARS MONTHS DAYS
(a) NET SERVICE THIS PERIOD
(b) PRIOR RESERVE COMPONENT SERVICE
(c) PRIOR ACTIVE FEDERAL SERVICE
(d) TOTAL SERVICE FOR PAY
(e) TOTAL SERVICE FOR RETIRED PAY
and as a Reserve of the National Guard of Report of separation and record of service in the
NATIONAL GUARD REPORT OF SEPARATION AND RECORD OF SERVICE
The proponent agency is ARNG-HRH. The prescribing directive is NGR 600-200.
1. LAST NAME- FIRST NAME- MIDDLE NAME
2. DEPARTMENT, COMPONENT AND BRANCH 3. SOCIAL SECURITY NUMBER
4. DATE OF ENLISTMENT
5a. RANK 5b. PAY GRADE 6. DATE OF RANK 7. DATE OF BIRTH
8a. STATION OR INSTALLATION AT WHICH EFFECTED 8b. EFFECTIVE DATE
9. COMMAND TO WHICH TRANSFERRED
11. TERMINAL DATE OF RESERVE/MILITARY SERVICE OBLIGATION
14. HIGHEST EDUCATION LEVEL SUCCESSFULLY COMPLETED
16. SERVICEMAN'S GROUP LIFE INSURANCE COVERAGE
17. PERSONNEL SECURITY INVESTIGATION
12. MILITARY EDUCATION
(Course Title, number of weeks, month and year completed)
13. PRIMARY SPECIALTY NUMBER , TITLE AND DATE AWARDED
(Additional specialty numbers and titles)
SECONDARY/HIGH SCHOOL
COLLEGE
YRS
(Gr 1-12)
YRS
15. DECORATIONS, MEDALS, BADGES, COMMENDATIONS,
CITATIONS AND CAMPAIGN RIBBONS AWARDED THIS PERIOD
(State Awards may be included)
YES NO AMT
a. TYPE b. INVESTIGATION
18. REMARKS
19. MAILING ADDRESS AFTER SEPARATION 20. SIGNATURE OF PERSON BEING SEPARATED
22. SIGNATURE OF OFFICER AUTHORIZED TO SIGN
23. AUTHORITY AND REASON
24. CHARACTER OF SERVICE
27.
25. TYPE OF CERTIFICATE USED 26. REENLISTMENT ELIGIBILITY
21. NAME, GRADE AND TITLE OF AUTHORIZING OFFICER
(Street, City, County, State, and Zip Code)
REQUEST DECLINE COPIES OF MY NGB FORM 22 INITIALS
1. AUTHORITY: Title 10 USC 12101 and 12103, Title 32 USC 301 and 304, and Executive Order 9397.
2. PURPOSE: Official discharge document, which records the National Guard member’s (ARNG & ANG) service in the National Guard. The original and
one copy will be provided to the soldier. A copy will be maintained by the MILPO for state records. For organizational use only.
3. ROUTINE USES: None.
4. DISCLOSURE: Voluntary; However, failure to provide Service Number may result in a delayed or erroneous processing of NGB Form 22A.
PRIVACY ACT STATEMENT
State
Click to sign
Click to sign
(USE PREVIOUS EDITIONS UNTIL EXHAUSTED)
NGB FORM 22, 20140731