ARMY CHESS TOURNAMENT APPLICATION

For use of this form, see AR 215-1; the proponent agency is OACSIM.

AUTHORITY: 10 U.S. Code 3013.

PRINCIPAL PURPOSE: Identification of participants in the Army Chess Tournament.

ROUTINE USES: Used to accept entries in the Army Chess Tournament and monitor participation. Information furnished
may be disclosed to any DOD component or part thereof, and upon request, to other Federal, State, or
local Government agencies in the pursuit of their official duties. Also, it may be disclosed to news media
in announcing contest participation and results. Finally, it may be used for other lawful purchases,
including law enforcement and/or litigation.

DISCLOSURE: Disclosure is voluntary. If the requested information is not provided, the individual may be
precluded from participation in this Army Chess Tournament.

1. NAME (Last, First, MI) 2. RANK (By Name, i.e., Captain)

3. MILITARY ADDRESS (Organization, Unit, State, P.O., APO, and 4. IMA REGION 5. DUTY TELEPHONE NO.
Zip Code) (Autovon/Commercial)

6. RECORD OF SIGNIFICANT CHESS ACTIVITY DURING THE LAST TWO YEARS (Use separate sheet, if necessary)
DATE PLACE EVENT STANDING/PLACE
(a) (b) (c) (d)

7. U.S. CHESS FEDERATION MEMBERSHIP CARD IDENTIFICATION NUMBER AND STATE OF REGISTRATION

a. U.S. CHESS FEDERATION b. DATE OF RATING c. DATE AND LOCATION OF LAST U.S. CHESS FEDERATION
RATING TOURNAMENT

8. I DID 9. INSTALLATION IDENTIFICATION (If applicable)

DID NOT PARTICIPATE IN AN INSTALLATION

QUALIFYING TOURNAMENT.

10. I DID 11. IMA REGION IDENTIFICATION (If applicable)

DID NOT PARTICIPATE IN AN IMA REGION

QUALIFYING TOURNAMENT.

12. CURRENT DUTY ASSIGNMENT (Clerk, Medic, etc.) 13. SIGNATURE 14. DATE

DA FORM 4878, JUN 2004 DA FORM 4878, AUG 90 IS OBSOLETE APD LC v1.00