CAUTION: NOT TO BE USED FOR THIS IS AN IMPORTANT RECORD.

ANY ALTERATIONS IN SHADED AREAS

IDENTIFICATION PURPOSES SAFEGUARD IT. RENDER FORM VOID

CERTIFICATE OF RELEASE OR DISCHARGE FROM ACTIVE DUTY

1. NAME (Last, First, Middle)
CHURCHWELL,
4.a. GRADE, RATE OR RANK
CALEB, EUGENE
12. DEPARTMENT, COMPONENT AND BRANCH
HOMELAND SECURITY:
5. DATE OF BIRTH
USCG
(YYYYMMDD)
..,
3. SOCIAL SECURITY NUMBER

16. RESERVE OBLIGATION TERMINATION DATE

I to I 5294
pAY GRADE
SA E2 1982 04 13 (YYYYMMDD) 2011 03 24
7.a. PLACE OF ENTRY INTO ACTIVE DUTY b. HOME OF RECORD AT TIME OF ENTRY (City and state, or complete address if known)

KANSAS CITY, MO
JOPLIN, MO 64801
8.a. LAST DUTY ASSIGNMENT AND MAJOR COMMAND b. STATION WHERE SEPARATED
USCG ANT FORT MACON, NC USCG GROUP FORT MACON, NC
9. COMMAND TO WHICH TRANSFERRED 10. SGLI COVERAGE '---.J NONE
AMOUNT: $250,000
"'=-
~ ~~RIMARY SPECIALTY (List number, title and years and months in 12. RECORD OF SERVICE YEAR(S) MONTH(S) DAY(S)
specialty. List additional specialty numbers and titles involVing periods of
one or more years). a. DATE ENTEREDAD THIS PERIOD 2003 03 25
b. SE~V"'~TION DATE THIS PERIOD 2005 03 03
NA
~ET ACTIVE SERVICETHIS PEmOD 01 11 08
X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X
'd. TOTAL PRIORACTIVE SERVICE 00 00 00

X X X X X X X X X X X X X X X X X X X X X X X e. TOTAL PRIORINACTIVESERVICE 00 00 00

X X X X X X X X X X X X X X X X X X X X X X X 1/'f:):OREIGN SERVICE 00 00 00
X X X X X X X X X X X X X X X X X X X X X X X g:lEA SERVICE 00 00 00
"h. EFFECTIVEDATE OF PAY GRADE 2003 05 16
13. DECORATIONS, MEDALS, BADGES, CITATIONS AND CAMPAIGN 14. MILITARY EDUCATION (Course title, number of weeks, and month and
RIBBONS AWARDED OR AUTHORIZED (All periods of service) year completed)
CG MERIT. UNIT COMMENDATION; TCT-UNIT, (O/WKS) NOV 2003; CAPE MAY RECRUIT,
X X X X X X X X X X X X X X X X X X X X X X X (7/WKS)MAY 2003; CR/HRA BASIC HUMAN
X X X X X X X X X X X X X X X X X X X X X X X AWARENESS (, (O/WKS) APR 2003; CR/HRA SEXUAL
X X X X X X X X X X X X X X X X X X X X X X X HARASSMENT PREV, (O/WKS) APR 2003;
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

15.a. MEMBER CONTRIBUTED TO POST-VIETNAM ERA VETERAN'S EDUCATIONAL ASSISTANCE PROGRAM

b. HIGH SCHOOL GRADUATE OR EQUIVALENT h-1 X
YES
YES
~ NO
NO
16. DAYS ACCRUED LEAVE 117. MEMBER WAS PROVIDED COMPLETE DENTAL EXAMINATION AND ALL APPROPRIATE YES NO
PAID 0.0 DENTAL SERVICES AND TREATMENT WITHIN 90 DAYS PRIOR TO SEPARATION X
18. REMARKS
HOME OF RECORD AT TIME OF ENTRY ON ACTIVE DUTY: JOPLIN, MO.
PLACE OF BIRTH: JOPLIN, MO.
MEMBERS INITIAL SERVICE CONTRACT WAS FOR FOUR YEARS.
ADVISED OF REQUIREMENTS FOR SELECTIVE SERVICE REGISTRATION.
ISSUED DD FORM 256CG.
X X X X X X X X X XX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
The information contained herein is subject 10 computer matching within the Department of Defense or with any other effected Federal or non-federal agency for
verification purposes and to determine eligibility for and/or continued compliance with the requirements of a Federal benefit program.
19.a. MAILING ADDRESS AFTER SEPARATION (Include lip Code) b. NEAREST RELATIVE (Name and address - include lip Code)
421 S. SERGEANT CHRIS CHURCHWELL
421 S. SERGEANT
JOPLIN, MO 64801
JOPLIN, MO 64801
20. MEMBER REQUESTS COPv)6 BE SENT TO NC DIREC OR OF VETERAN AFFAIRS I X IYES NO
TED . ~eIAfjtH~ IZED TO SIGN (Typed name, grade, title and signature)
2~~
EB EUGB E CHURCHWELL
22~~

T'Y
.~. ,~
. BAR't:.ON, Yr< 1, USCG, BYDIR

(For use by authorized agencies only)

23. TYPE OF SEPARATION 24. CHARACTER OF SERVICE (Include upgrades)
DISCHARGE HONORABLE
25. SEPARATION AUTHORITY 26. SEPARATION CODE
COMDTINST, M1000.1A 12-B-16 JNC
28. FOR SEPARATION
UNACCEPTABLE CONDUCT
29. ING THIS PERIOD 30. MEMBER REQUESTS COPY 4
TL: NONE Initials CEC
DD FORM 214, FEB 2000