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1. I, (name and number) was, on (insert date) and while holding the rank of in NCIS, found to have committed the disciplinary offence(s) mentioned in the first column below with which I had been charged and was punished therefor as mentioned in the second column below, [such punishment(s) being varied on appeal to the punishment(s) mentioned in the third column below]:
| Offence proved | Punishment therefor | Varied on appeal to |
|---|---|---|
1. | 1. | 1. |
2. | 2. | 2. |
3. | 3. | 3. |
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