ETA 6131 C Right to Appeal

OMB Control Number 12-5-0219
Expires: 02/28/2013
Public Burden Statement
Reason for Appeal
U.S. DEPARTMENT OF LABOR

• Employment and Training Administration
Office of Job Corps

RIGHT TO APPEAL

(Check one)

Decision to discharge
(Center Director)
Recommendation for disciplinary
discharge (Center Review Board)

I have been informed of my right to have a reasonable amount of
time in which to submit an appeal. If I decide to appeal I may
given the assistance of any individuals on cent er to prepare the written and signed statement.
S tu d e n t N a m e

S o c i a l S e c u r i ty N u m b e r

D a te

be

( M o n th , D a y , Y e a r )

Check One
I elect:

not to appeal

to appeal for the following reasons: (

S tu d e n t’ s S i g n a tu r e a n d D a te

(Formerly JC Forms 144C and 144D)

If additional space is needed, use reverse)

D a te A p p e a l R e c e i v e d b y C e n te r
Director
U.S. Governme

nt Printing Office: 1977-720.665.6677 3.1

ETA 6-131C (Apr. 197

7)