Ahrc Form 1046 2 E – Fill Out and Use This PDF

P R I V ACY ACT I N FO R M AT I O N : T h e a u t h o r it y f o r co lle ct io n o f in f o r m a t io n is T it le 1 0 , U . S. Co d e , se ct io n 1 5 5 2 , EO 9 3 9 7 . T h e p r in cip a l p u r p o se is f o r t h e

e n r o llm e n t o f st u d e n t s a t W o m a ck Ar m y M e d ica l Ce n t e r ( W AM C) . Ro u t in e U se : N o n e . D isclo su r e is v o lu n t a r y ; h o w e v e r , f a ilu r e t o p r o v id e id e n t if y in g in f o r m a t io n m a y im p e d e y o u r a b ilit y t o r e q u e st a n d e n r o ll a t W AM C.

APPLICATION FOR RENEWAL OF EDUCATIONAL DELAY FROM ENTRY ON ACTIVE DUTY AND VERIFICATION OF ENROLLMENT IN GRADUATE OR PROFESSIONAL SCHOOL

NOTIFICATION. UNDER THE PRIVACY ACT OF 1974

The Social Security Number (SSN) and current mailing adddress requested under Part 1 on this form are mandatory under Title 10, US Code, Section 275, 1001, and 4301. These items will be used for purpose of identification and maintenance. Failure to provide these items may result in the rmoval from delayed entry status, and subject the member to be called to active duty.

PART 1 - ADDRESS INFORMATION

1. NAME (LAST, FIRST, MI)	2. RANK	3. SOCIAL SECURITY NUMBER - LAST FOUR

6. TELEPHONE NUMBER (INCLUDE AREA CODE)				7. BRANCH (e.g. Inf, AG)			8. EMAIL ADDRESS
(H)	(W)				DL/MSC
			PART II - DELAY INFORMATION
9: MAJOR FIELD OF GRADUATE STUDY		10. DEGREE OBJECTIVE				11. NAME AND ADDRESS OF INSTITUTION IN WHICH CURRENTLY
		(CHECK	ONE)			ENROLLED
		❑ MA or MS		❑ PhD
		❑ Other

12.-DATE DEGREE EXPECtED-TO BE AWARDED -13. DATE DELAY_ TO.COMMENCE		14. ,DATE DELAY TO,END (MONTH AND YEAR)
(MONTH AND Year)	(Month and Year)	Note: Renewal coannot exceed 1 year from Delay Commencement
	JUNE	JUNE
	PART III - DELAY NOT REQUESTED

PART IV - CONDITIONS & MEDICAL CERTIFICATE

16.I agree to the conditions below if my request for renewal of delay is approved:

a. The determination as to whether I will serve on active duty for training as set forth in the Supplemental Agreement attached hereto upon termination

of my delay status rests witht he Department of the Army.

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b.I will be required to serve on active duty or active duty for training and in the Army Reserve as set forth in the Supplemental Agreement attached hereto.

c.I may be subject to transfer or reappointments to a different branch of service which would be more consistent with my post graduate subject discipline and military requirements.

d.My delay status may be terminated at any time by the Department of the Army because of overriding military requirements.

e.I will not be authorized delay for educational reasons when I obtain the degree indicated in item 10 of this from.

f.My active duty availability date will be the month following the month and year indicated in item 12, unless I am authorized further delay for other reasons, and I will be scheduled for active duty as soon as possible after my active duty availability date.

g.I realize that this is an annual renewal and cannot exceed one year from the date of commencement indicated in item 12 of this form.

17.CERTIFICATE OF PHYSICAL CONDITION. I CERTIFY TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT I HAVE NO MEDICAL CONDITION OR PHYSICAL DEFECT WHICH WOULD PREVENT MY PERFORMANCE OF ACTIVE MILITARY SERVICE EXCEPT AS FOLLOWS:

YES / NO ❑

If your answer is YES please provide supporting documents or attach them.

INSTRUCTIONS - Please Print of Type

PART I - ADDRESS INFORMATION - All items in Part I are to be completed. Please type or print legibly your name and complete address,

including zip code, since this will be used for mailing purposes.

PART II - DELAY INFORMATION -Items 9 thru 14 are to be completed by each officer requesting renewal of educational delay.

PART III - DELAY NOT REQUESTED - Item 15 is to be completed only if officer is not requesting renewal of educational delay.

PART IV - CONDITIONS & MEDICAL CERTIFICATE - Items 16 thru 17 should be carefully read and then signed by each officer requesting renewal of

educational delay. Any medical condition or physical defects indicated must be accompanied by 8 statemnt-from your doctor or to support your claim. Such statement must include diagnosis; date of illness or injury; prognosis;- expected date of recovery; and whether the disabilit is Considered temporary or permaned in nature.

RETURN COMPLETED FORM TO U.S. Army Human Resources Command, ATTN: AHRC-OPH-PAI Incentives Branch,

1600 Spearhead Division Ave Dept #270, Fort Knox, KY 40122

WARNING: Emailing of this information is at the discretion of the applicant and uses the applicant’s email system. Womack Army Medical Center does NOT assume any liability for the interception of the information contained on this form. Use the following site for encrypting any emails sent to WAMC: https://safe.amrdec.army.mil/SAFE/Welcome.aspx

IRC FORM 1046-2-E, JAN 2012					Page 2 of 2