Military Authorization Change Request Form
Use this form to request a change to an existing military authorization and provide the details needed for review and processing.
Requester Information
Full Name
*
First Name
Middle Name
Last Name
Rank or Role
*
Branch or Service Affiliation
*
Please Select
Army
Navy
Air Force
Marine Corps
Space Force
Coast Guard
Other
Unit or Department
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Current Authorization Details
Current authorization name or title
*
Authorization reference code
Current status
*
Please Select
Active
Pending
Suspended
Expired
Revoked
Other
Original issue or effective date
*
 -
Month
 -
Day
Year
Date
Requested Authorization Change
Type of Change Requested
*
Update
Correction
Extension
Revocation
Replacement
Reassignment
Other
Description of Requested Change
*
Effective Date of Change
*
 -
Month
 -
Day
Year
Date
Reason for Change
*
Impacted Privileges, Assignments, or Responsibilities
Access privileges
Assigned unit or team
Duties or responsibilities
Duty location
Reporting chain
Equipment or resource access
Training or certification requirement
Other
Supporting Details and Submission
Additional Notes or Instructions
Supporting Documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Acknowledgment Signature
*
Submit Request
Submit Request
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