Department of Health and Human Services	Public Health Service
		Centers for Disease Control and Prevention (CDC) Atlanta GA 30333

I request approval for voluntary retirement from the Commissioned Corps of the U.S. Public Health Service effective      . At that time, I will have completed a minimum of 20 years active duty. By my signature below, I certify that I am aware that this date will be the effective date of my retirement and cannot be changed after Personnel Orders have been issued.

After a productive and meaningful career, I am requesting this retirement to pursue personal interests.

By my signature below, I certify that I am aware of the requirement for voluntary retirement with less than 30 years service that the PHS certify that my services are no longer needed.

I. Am Officer
Rank, USPHS