Exhibits_A _B _and_D_-_EBFL_CDRLs.docx

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Amendment 2
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M67854-14-R-5011
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Exhibits A B and C - CDRLs

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CONTRACT DATA REQUIREMENTS LIST

(1 Data Item) Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ _ TM _ _ OTHER __X__

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

17. PRICE GROUP

1. DATA ITEM NO.

B001

2. TITLE OF DATA ITEM

Initial Technical Inspection Report

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-NDTI-80809B

5. CONTRACT REFERENCE

SOW para 3.1.2

6. REQUIRING OFFICE

MARCORSYSCOM, PM-CSS, PdM-ES18. ESTIMATED TOTAL PRICE

7. DD 250 REQ

DD

9. DIST

STATEMENT

D

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

SEE BLK 16

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION ASREQ

Draft
Final
Reg
Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C., App. 2401 et seq. Violation of these export laws are subject to severe criminal penalties. Disseminate in accordance with the provisions of DoD Directive 5230.25

BLK 12 - Submit draft format 7 days prior to Post Award Meeting. The Government requires 14 days to review and comment. Submit final format, with Government comments incorporated, 7 days after receipt of Government comments.

BLK 13 - Submit reports 14 days after completion of initial technical inspection.

BLK - 14 Submission shall be via Electronic mail (E-mail) to the addresses below. All deliverables will use Microsoft Office 2007 or 2010 software (MS Word, MS Excel, MS PowerPoint).

MCSC (PM-CSS):

Michael.Asghedom@usmc.mil Philip.Dombek@usmc.mil David.Moyer@usmc.mil Michael.j.Farley@usmc.mil

Letters of transmittal only shall be provided to the following address:

MCSC (CTQ):

Stasia.Baker@usmc.mil

MCSC:

(PdM-ES)
4
0
4
(CTQ)
1
0
1
DCMA
1
0
1
15. TOTAL ---------
6
0
6

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

CONTRACT DATA REQUIREMENTS LIST

Form Approved

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ _ TM _ _ OTHER __X__

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

1. DATA ITEM NO.

B002

2. TITLE OF DATA ITEM

Master Control Document

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-MGMT-80442

5. CONTRACT REFERENCE

SOW para 3.2.1

6. REQUIRING OFFICE

7. DD 250 REQ

9. DIST

STATEMENT

D

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION ASREQ

Draft
Final
Reg
Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C., App. 2401 et seq. Violation of these export laws are subject to severe criminal penalties. Disseminate in accordance with the provisions of DoD Directive 5230.25

BLK 12 - Submit draft format 7 days prior to Post Award Meeting. The Government required 14 days to review and comment. Submit final format, with Government comments incorporated, 7 days after receipt of Government comments.

BLK 13 - Submit quarterly after final format approval. Begin submitting monthly after Production Readiness Review.

BLK - 14 Submission shall be via Electronic mail (E-mail) to the addresses below. All deliverables will use Microsoft Office 2007 or 2010 software (MS Word, MS Excel, MS PowerPoint).

MCSC (PM-CSS):

Michael.Asghedom@usmc.mil Philip.Dombek@usmc.mil Michael.j.Farley@usmc.mil

Letters of transmittal only shall be provided to the following address:

MCSC (CTQ):

MCSC:

(PdM-ES)
3
0
3
(CTQ)
1
0
1
DCMA
1
0
1
15. TOTAL ---------
5
0
5

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

CONTRACT DATA REQUIREMENTS LIST

Form Approved

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ _ TM _ _ OTHER __X__

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

1. DATA ITEM NO.

B003

2. TITLE OF DATA ITEM

MEETING MINUTES

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-ADMN-81250A

5. CONTRACT REFERENCE

SOW para 3.3.1

6. REQUIRING OFFICE

7. DD 250 REQ

9. DIST

STATEMENT

D

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION ASREQ

Draft
Final
Reg
Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C., App. 2401 et seq. Violation of these export laws are subject to severe criminal penalties. Disseminate in accordance with the provisions of DoD Directive 5230.25

BLK 12 - Submit draft minutes within 10 days after each conference, meeting, audit or reeview. The Government requires 10 days to review and comment. Submit final, with Government comments incorporated, 7 days after receipt of Government comments.

BLK - 14 Submission shall be via Electronic mail (E-mail) to the addresses below. All deliverables will use Microsoft Office 2007 or 2010 software (MS Word, MS Excel, MS PowerPoint).

MCSC (PM-CSS):

Michael.Asghedom@usmc.mil Philip.Dombek@usmc.mil David.Moyer@usmc.mil Michael.j.Farley@usmc.mil

Letters of transmittal only shall be provided to the following address:

MCSC (CTQ):

MCSC:

(PdM-ES)
4
0
4
(CTQ)
1
0
1
DCMA
1
0
1
15. TOTAL ---------
6
0
6

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

CONTRACT DATA REQUIREMENTS LIST

Form Approved

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ _ TM _ _ OTHER __X__

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

1. DATA ITEM NO.

A001

2. TITLE OF DATA ITEM

CORROSION PREVENTION AND CONTROL PLAN

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-MFFP-81403

5. CONTRACT REFERENCE

SOW para 3.4.4

6. REQUIRING OFFICE

7. DD 250 REQ

9. DIST

STATEMENT

D

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION ASREQ

Draft
Final
Reg
Repro

16. REMARKS

BLK 4 - All references to MIL-STD-1568 do not apply. MIL-HDBK-1568 may be used for guidance.

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C., App. 2401 et seq. Violation of these export laws are subject to severe criminal penalties. Disseminate in accordance with the provisions of DoD Directive 5230.25.

BLK 12 - Submit draft CPCP 15 calendar days prior to CDR. The Government requires 30 calendar days to review and comment. The contractor shall submit final 30 calendar days after receipt of government comments.

BLK - 14 Submission shall be via Electronic mail (E-mail) to the addresses below. All deliverables will use Microsoft Office 2007 or 2010 software (MS Word, MS Excel, MS PowerPoint).

MCSC (PM-CSS):

Michael.Asghedom@usmc.mil David.Moyer@usmc.mil Michael.j.Farley@usmc.mil

Letters of transmittal only shall be provided to the following address:

MCSC (CTQ):

MCSC:

(PdM-ES)
3
0
3
(CTQ)
1
0
1
15. TOTAL ---------
4
0
4

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

CONTRACT DATA REQUIREMENTS LIST

Form Approved

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ X_ TM _ _ OTHER ____

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

1. DATA ITEM NO.

A002

2. TITLE OF DATA ITEM

PRODUCT DRAWINGS/MODELS AND ASSOCIATED LISTS

3. SUBTITLE

Engineering / Configuration

4. AUTHORITY (Data Acquisition Document No.)

DI-SESS-81000D

5. CONTRACT REFERENCE

SOW para 3.8

6. REQUIRING OFFICE

7. DD 250 REQ

9. DIST

STATEMENT

D

10. FREQUENCY

ASREQ

12. DATE OF 1ST SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION SEE BLK 16

Draft
Final
Reg
Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

Blocks 12 & 13 – In-process format review: No later than 60 days after contract award the contractor/developer shall submit a sample of the various types of drawings (assembly, control, detail, etc.) and lists (parts, data, and index) which will be furnished in the final drawing package. The format review drawings shall be submitted as both regular and reproducible draft copies as stipulated in Block 14 of this CDRL and the attachments to this CDRL. The Government will review the submitted data to ensure compliance with contractual requirements. All other drawings developed under this contract shall adhere to the format approved by the Government.

90% Review: 15 days prior to the CDR the contractor shall submit 90% of the drawing package including indentured BOM to the government for review.

In-process technical review: The contractor/developer shall submit a copy of the completed drawing package 60 days after approval of inspection and test report. When the contractor/developer has received comments resulting from the Government in-process technical review, the contractor/developer shall review the Government comments, make corrections to the entire package and resubmit all new and revised drawings within 30 days of comment receipt. Government comments, whether directed against a specific drawing, or made as a general comment, may apply to other drawings that have not been reviewed by the Government. The Government will subject resubmitted drawings and other drawings not previously reviewed to another technical review. Any additional comments generated as a result of subsequent technical reviews shall also be furnished to the contractor/developer for action. This process shall be repeated as necessary. Response time for each submittal thereafter shall be 15 days.

Final delivery: The contractor/developer shall submit the final drawing package 30 days after the Physical Configuration Audit.

Block 14 – In-process format review: Each number indicates one draft regular and one draft reproducible copy of the drawings and associated list as described in Block 12 &13 of this CDRL and attachments 1 and 2 to this CDRL.

90% and In-process technical review: Each number indicates one draft regular copy of the complete drawing package and associated list in electronic format in accordance with attachments 1 and 2 to this CDRL.

Final delivery: Each number indicates one complete data set for each of the following: final regular electronic copy, final reproducible copy and Gerber data for printed wiring boards in accordance with attachments 1 and 2 to this CDRL.

Final submittals shall be by DD Form 250, as indicated in Block 7.

MCSC (PdM-ES, PM-CSS):

Michael.j.Farley@usmc.mil Michael.Asghedom@usmc.mil David.Moyer@usmc.mil

MCSC:

(PdM-ES)
3
0
3
(ALBANY 572-2)
1
0
1
15. TOTAL ---------
4
0
4

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

CONTRACT DATA REQUIREMENTS LIST

Form Approved

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ _ TM _ _ OTHER __X__

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

1. DATA ITEM NO.

D001

2. TITLE OF DATA ITEM

LSA-036

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-ILSS-80114

DI-ILSS-80114

5. CONTRACT REFERENCE

SOW para 4.5.4.7

6. REQUIRING OFFICE

7. DD 250 REQ

9. DIST

STATEMENT

D

10. FREQUENCY

R/ASR

12. DATE OF 1ST SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION SEE BLK 16

Draft
Final
Reg
Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C., App. 2401 et seq. Violation of these export laws are subject to severe criminal penalties. Disseminate in accordance with the provisions of DoD Directive 5230.25

BLK 12 – Submit draft 60 days after contract award.

BLK 13 – Submit advance copies 30 days prior to each provisioning meeting . Submit updated LSA-036 within 30 days from the completion of each provisioning meeting.

BLK - 14 Submission shall be via Electronic mail (E-mail) to the addresses below. All deliverables will use1388-2B Format.

MCSC (PM-CSS):

Michael.Asghedom@usmc.mil Philip.Dombek@usmc.mil

Letters of transmittal only shall be provided to the following address:

MCSC (CTQ):

MCSC:

(PdM-ES)
4
0
4
(CTQ)
1
0
1
15. TOTAL ---------
5
0
5

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

CONTRACT DATA REQUIREMENTS LIST

Form Approved

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

C. CATEGORY:

TDP _ _ TM _ _ OTHER __X__

D. SYSTEM/ITEM

Extendable Boom Forklift

E. CONTRACT/PR NO.

F. CONTRACTOR

1. DATA ITEM NO.

D002

2. TITLE OF DATA ITEM

TM Validation Plan

3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-TMSS-81818

5. CONTRACT REFERENCE

SOW para 5.12.1

6. REQUIRING OFFICE

7. DD 250 REQ

9. DIST

STATEMENT

D

10. FREQUENCY

R/ASR

12. DATE OF 1ST SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE
b. COPIES

8. APP CODE

A

11. AS OF DATE

13. DATE OF SUBSEQUENT SUBMISSION SEE BLK 16

Draft
Final
Reg
Repro

16. REMARKS

BLK 9 - The following information shall be included on the deliverable: DISTRIBUTION STATEMENT D: Distribution authorized to the Department of Defense and U.S. DoD contractors only; Administrative-Operational Use; 01 January 2009. Other requests shall be referred to Commander, MARCORSYSCOM( PM-CSS, PdM-ES), 2200 Lester Street, Quantico, VA 22134-6050

WARNING: This document contains technical data whose export is restricted by the Arms Export Control Act (Title 22, U.S.C., sec. 2751, et seq.) or the Export Administration Act of 1979, as amended, Title 50, U.S.C., App. 2401 et seq. Violation of these export laws are subject to severe criminal penalties. Disseminate in accordance with the provisions of DoD Directive 5230.25

BLK 12 – Submit draft 30 days after contract award. The Government requires 30 days to review and comment.

BLK 13 –Submit final format, with Government comments incorporated, 7 days after receipt of Government comments.

BLK - 14 Submission shall be via Electronic mail (E-mail) to the addresses below. All deliverables will use Microsoft Office 2007 or 2010 software (MS Word, MS Excel, MS PowerPoint).

MCSC (PM-CSS):

Michael.Asghedom@usmc.mil Philip.Dombek@usmc.mil

Letters of transmittal only shall be provided to the following address:

MCSC (CTQ):

Stasia.Baker@usmc.mil

MCSC (PM-CSS Albany) John.Henson@usmc.mil

MCSC:

(PdM-ES)
2
0
2
(CTQ)
1
0
1
(PdM-ES Albany)
1
0
1
15. TOTAL ---------
4
0
4

G. PREPARED BY

H. DATE

I. APPROVED BY

J. DATE

DD Form 1423-1, FEB 2001
PREVIOUS EDITION MAY BE USED
Page __ of __ Pages

File details come from the government source that posted it. Updated .