US Army Center for Health Promotion and Preventive Medicine
Training & Conferences

Registration/Application Request

Basic Waste Management for Healthcare Personnel
IT IS MANDATORY THAT YOU CHECK THE BOX FOR THE CLASS DATE OF YOUR CHOICE. REGISTRATION FORMS WITHOUT A SPECIFIED DATE WILL BE DISCARDED.
   17 - 20 August 2004, Fort Hood, TX             16 - 19 November 2004, Baltimore, MD             14 - 17 June 2005, Seattle, WA
Privacy Act Statement
 Title 5 US Code, Section 301; Executive Order 9397 authorizes the use of your Social Security Number as an identification number. The purpose of this information is for recordkeeping only. Having read the preceding Privacy Act Statement submission of this electronic form indicates applicants consent.
Fields marked with a red * are required. Use the TAB Key to navigate from field to field.
*Name:               
*Job Series&#47AOC:   
*Grade/Rank          
*Social Security Number:   
*Job Title:          
Component: Army, Navy, Civilian DAC, (Non-Gvt)/ Contractor, etc:   
Gender:   Male   Female
Office Mailing Address
DSN Phone              
Comm Phone             
Fax Number             
*E-Mail Address:     
                    AKO E-Mail Address:   
                    Alternate E-Mail Address:   
Have you ever attended a Waste Management Crs. conducted by CHPPM?   Yes   No
If yes, which one and when:   
Would you be able to attend on short notice if someone else cancels?    Yes   No
Provide a brief description of your current dutiesś responsibilities :
It is necessary for the applicant to have verbal supervisory approval before submission of this form.
Supervisor's Name      
Supervisor's Title     
Supervisor's E-Mail    
Supervisor's Phone