DA Form 4230-R Supplemental Signature Sheet (Lra)

DA Form 4230-R or the "Supplemental Signature Sheet (lra)" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 4230-R - was last revised on April 1, 1993. Download an up-to-date fillable DA Form 4230-R down below in PDF-format or look it up on the Army Publishing Directorate website.

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SUPPLEMENTAL SIGNATURE SHEET
For use of this form, see AR 27-60; the proponent agency is OTJAG
Use this form with DA Forms 2873-R and 2874-R when additional signature blocks are needed.
1. ASSIGNOR(s) OR LICENSOR(s) NAME(s)
2. APPLICATION SERIAL NUMBER
3. FILING DATE
4. TITLE OF INVENTION
SIGNATURE OF INVENTOR:
(First name)
(Middle initial)
(Last name)
DUTY ADDRESS:
DATE SIGNED:
INVENTOR'S TYPED NAME:
* * * * * * * * * * * * *
STATE OF
)
) SS.
COUNTY OF
)
On the above date
known to me to be the individual described in and who
executed the foregoing instrument duly appeared before me and acknowledged to me that he executed the same as his own
free act and deed.
(SEAL)
(Signature of notary public)
My Commission expires on
SIGNATURE OF INVENTOR:
(First name)
(Middle initial)
(Last name)
DUTY ADDRESS:
DATE SIGNED:
INVENTOR'S TYPED NAME:
* * * * * * * * * * * * *
)
STATE OF
) SS.
)
COUNTY OF
On the above date
known to me to be the individual described in and who
executed the foregoing instrument duly appeared before me and acknowledged to me that he executed the same as his own
free act and deed.
(SEAL)
(Signature of notary public)
My Commission expires on
Page
of
Pages
DA FORM 4230-R, APR 1993
REPLACES DA FORM 4230-R, MAR 74, WHICH IS OBSOLETE
APD LC v2.00
SUPPLEMENTAL SIGNATURE SHEET
For use of this form, see AR 27-60; the proponent agency is OTJAG
Use this form with DA Forms 2873-R and 2874-R when additional signature blocks are needed.
1. ASSIGNOR(s) OR LICENSOR(s) NAME(s)
2. APPLICATION SERIAL NUMBER
3. FILING DATE
4. TITLE OF INVENTION
SIGNATURE OF INVENTOR:
(First name)
(Middle initial)
(Last name)
DUTY ADDRESS:
DATE SIGNED:
INVENTOR'S TYPED NAME:
* * * * * * * * * * * * *
STATE OF
)
) SS.
COUNTY OF
)
On the above date
known to me to be the individual described in and who
executed the foregoing instrument duly appeared before me and acknowledged to me that he executed the same as his own
free act and deed.
(SEAL)
(Signature of notary public)
My Commission expires on
SIGNATURE OF INVENTOR:
(First name)
(Middle initial)
(Last name)
DUTY ADDRESS:
DATE SIGNED:
INVENTOR'S TYPED NAME:
* * * * * * * * * * * * *
)
STATE OF
) SS.
)
COUNTY OF
On the above date
known to me to be the individual described in and who
executed the foregoing instrument duly appeared before me and acknowledged to me that he executed the same as his own
free act and deed.
(SEAL)
(Signature of notary public)
My Commission expires on
Page
of
Pages
DA FORM 4230-R, APR 1993
REPLACES DA FORM 4230-R, MAR 74, WHICH IS OBSOLETE
APD LC v2.00

Download DA Form 4230-R Supplemental Signature Sheet (Lra)

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