Military Separation Data Form

Service Member Full Name

First NameMiddle NameLast Name

Branch of Service

Current Rank/Grade

Separation Date

Date

Separation Type

Separation Reason

Separation Authority / Unit

Preferred Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Email Address

example@example.com

Current Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Additional Notes / Follow-up Instructions