Registration/Application Request

Course Dates:

Incomplete applications will not be processed

4-8 Feb 2013 at Edgewood Aberdeen Proving Grounds

11-15 March 2013 at Edgewood Aberdeen Proving Grounds

29 April- 3 May 2013 at Edgewood Aberdeen Proving Grounds

3-7 June 2013 at Edgewood Aberdeen Proving Grounds

22-26 July 2013 at Edgewood Aberdeen Proving Grounds

*Name (Last, First):                         *Job Series # :                         *Grade/Rank

*Job Title

Gender:    Male    Female

Emergency Contact Information:

Phone Number            Name (Last, First)

Component Army, Navy, Air Force, ARNG, Civilian, Contractor

Office Mailing Address

DSN Phone Number:    Commercial Phone Number:                        *E-Mail Address:

Is this the first time you've attended DOEHRS-IH Training?    Yes    No

Supervisor's Name       Supervisor's Title      Supervisor's E-Mail     Supervisor's Phone