AFGE

 

3 Wembley Court

Albany, New York 12205

Phone: (518) 218-7100

Fax: (518) 218-0496

E-mail: afge@tullylegal.com

www.tullylegal.com

www.afge.org

 

 

 

MILITARY LEAVE INTAKE FORM

 

Please fill in the following information so that we may better evaluate your eligibility for a MSPB claim under the Uniformed Services Employment and Reemployment Rights Act (USERRA).

 

Once both sheets are completed, please return to our office via email: afge@tullylegal (send complete form as an attachment or imbedded document), fax: (518) 218-0496, or postal mail: Tully, Rinckey & Associates, USERRA Intake, 3 Wembley Ct., Albany, NY 12205. Please allow 2-3 weeks from the time we receive this intake form to evaluate and start the initial processing of your paperwork. Incomplete, missing, or vague information may delay the processing of your claim.    

 

 

Contact Information:

 

NAME:   ___Mr.   ___Ms.     _____________________ญญญ________________________

 

 

HOME ADDRESS:            ____________________________________

 

                                    ____________________________________

 

 

HOME PHONE:             ____________________________________

 

 

OFFICE PHONE:            ____________________________________

 

 

CELL PHONE:               ____________________________________

 

 

EMAIL (home):              ____________________________________

 


EMAIL (work):                ____________________________________

 

 

Are you currently deployed out of the United States?  ___________________________

 

Military Service Information:

Beginning Date of Service: ____________________    

Ending Date:______________________

Which branch did you serve in?            ______________________________________


Any year(s) you did not use any military leave?            _______ญญญญ_________

 

 

 

Did you get charged military leave for non-workdays?             ____YES   ____NO   ____DONT KNOW

 

 

Were you forced to use any of the following due to the agency charging you on off-duty days?

                    ____ Annual Leave               ____Sick Leave               ____LWOP 

 

 

Have you filed any other military leave claims with your personnel office?           ___YES   ___NO

           

            If Yes, for which year(s) were you compensated for?   ______________

 

 

Federal Civilian Employment Information:

(If you have been employed by different Federal Departments, Agencies, and/ or Places of Duty, please list all with corresponding years of service starting with the most recent. Use additional pages if necessary.)  

 

Any break in civilian service?                                    ___YES   ___NO


When was break?                                      ____________

 

FEDERAL DEPARTMENT EMPLOYED BY:  (i.e. Dept. of Defense, Justice, Homeland Security, etc.)

                                               
_____________________________________

 

FEDERAL AGENCY: (i.e. Border Patrol, Immigration, Customs, Army, Secret Service, etc.)

                                               
_____________________________________

 

Place of Employment:            _________________________________________________


Address:                       ______________________________________

                                    ______________________________________

 


Beginning Date of Service: _________________       Ending Date: _____________________

                                                                                                           (if current, please indicate)