4013 Form 2016-2026

REMARKS NOTES PHS-4013-1 REV. 8/16 FRONT See Privacy Act on reverse PSC Publishing Services 301 443-6740 EF PRIVACY ACT STATEMENT for Form PHS-4013-1 Application for Shipment of Household Goods Commissioned Officers General This statement is provided pursuant to the Privacy Act of 1974 P. Department of Health and Human Services Public Health Service Commissioned Corps APPLICATION FOR SHIPMENT OF HOUSEHOLD GOODS COMMISSIONED OFFICERS Type or print* Forward the original with signature to the PHS Shipping Officer serving your station* Retain a copy for your records. 2. FROM Last name first name middle initial and rank of applicant 3. TELEPHONE NO. Applicant 1. TO Name and Address of Shipping Officer Type or print OFFICE HOME 4. PRESENT PERMANENT DUTY STATION Operating Division Bureau Division City State Zip NO. ROOMS 5. I hereby request that my household goods be transported as authorized by attached copy of PERSONNEL ORDER DATED NUMBER TRAVEL ORDER THIS ORDER AUTHORIZES SHIPMENT TO City and State This order DOES DOES NOT separate or inactivate me from active duty. 6. a I have previously shipped under order listed in Item 5 above b If YES list shipment s made below APPROX. WT. YES NO FROM G*B. L* NO. TO If known 7. SHIPMENT TO BE MADE FROM Street Address City State Zip 8. TO BE SHIPPED TO StreetAddress City State Zip WT. SHIPPED 9. DATE REQUESTED FOR PICKUP 10. DESIRED DATE OF APPROVAL 11. EXTRA LOCAL PICKUP Street Address City State Zip 12. EXTRA LOCAL DELIVERY Street Address City State Zip 13. MY MAILING ADDRESS WHILE GOODS ARE IN TRANSIT WILL BE 14. PERSON TO RECEIVE GOODS AT DESTINATION OR DESIGNATED AGENT 15. I REQUEST THAT MY GOODS BE PLACED IN STORAGE AT City and State 16. REMARKS OR ADDITIONAL INFORMATION 17. I certify that a The above requested shipment will consist of household goods in my possession prior to the effective date of my orders. c The following appliances will need technical servicing for safe transportation b The following items are necessary in the performance of my official duties Professional books Professional papers Yes No d I will immediately notify the origin shipping officer if my orders are modified or cancelled and affect this shipment. f I have not and will not make claim for trailer allowance. g Shipment of approximately pounds of my allowance by expedited mode is required to carry out assigned duties or prevent undue hardship to me and/or my dependents. e I will pay all excess costs incurred as a result of this shipment. This agreement will not prejudice my right to appeal such costs after payment is made. Other specify Signature of Applicant Date FOR ADMINISTRATIVE USE ONLY REPRESENTATIVE CONTACTED REPRESENTING Name of Company or Agent SHIPMENT CONFIRMED PER PICK-UP DATE NAME OF TRANSPORTATION COMPANY TENDERED TO Name of Agent Lot/s Household Goods Gross Tare Net Weight includes lbs. professional books papers etc* Excess distance miles Excess charges Excess weight Unauthorized services specify SIT-NTE 90 days at Name address and telephone number of Agent Total amount to be paid by commissioned corps member to Shipping Officer prior to shipment of goods when appropriate.