AGE WAIVER EXAMPLE:

ABCD-EFG

MEMORANDUM FOR COMMANDER, HQ USAREC ATTN: RCHS-SVD-PA 1307

Third Avenue, Fort Knox, KY 40121-2726

FOR Staff Sergeant Jane Q Doe, SSN 123-45-6789, U.S. Army Medical Department

Activity, Fort Jackson, SC 29207

SUBJECT: Interservice Physician Assistant Program Application AGE Waiver Request

(required only of over the age of 38 at the time of commissioning)

1. In accordance with AR 601-20, I am requesting a wavier for my age. 01 July 2016, I

will be ____ years of age.

2. I can be reached at the following address: 1234 Main St, Hometown, US 12345;

DSN 123-4567, commercial (123) 456-7890, or e-mail [email protected].

JANE Q DOE

SSG, USA

Combat Medic