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

Registration/Application Request

Intermediate Hygiene Topics (6H-F10)
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 w/ Middle Initial:   
*Job Series/AOC:        
*GradeRank:          
*Social Security Number:   
*Job Title:          
Component: Army, Navy, Civilian DAC, (Non-Gvt)/ Contractor, etc:   
Gender:   Male   Female
Complete Current Office Mailing Address:
DSN Phone Number:   
                    Commercial Phone Number:   
                    Commercial Fax Number:   
AKO/NKO E-Mail Address:    
                    *Work E-mail Address:   
Provide a brief description of your current duties and responsibilities:
How long have you been in your current position&#47assignment?    
List previous industrial hygiene related assignments and/or positions:
Educational background and dates:
Industrial Hygiene training, including attendance dates, (be sure to address the prerequisites, if any, stated in the course announcement):
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