APAOC General Membership Form

Page 1     Instructions   Please fill out the form accordingly and as complete as possible. Applications for general membership are accepted thruought the year. Eligibility: any Commissioned Corps (CC) officers or Civil Service (CS) personnel interested in the mission and goals of the APAOC.   1. First Name, Middle Initial, Last Name*         2. Work contact information   Street Address   City   State   Zip Code   Phone Number   Fax Number   E-mail         3. Please provide your job title         4. Please select your current agency/operating division (OPDIV)/program*   -- Please Select -- AHRQ ATSDR BOP CDC CIA CMS DHS DOD TMA EPA FDA HRSA IHS NIH NPS OS PSC SAMHSA USAMRMC USDA USMS Other       5. Please select your employment status   Active reserved corps   Active regular corps   Civil service   Civil service (inactive reserve corps)   Civil service (retired officer)   Retired   Other, please specify               6. Please select your professional category or discipline*   -- Please Select -- Dentist Dietitian Engineer Environmental Health Health Services Nurse Pharmacist Physician Scientist Therapist Veterinarian Other       7. Please select your PHS rank (for CC officers) or Civil Service Grade   -- None -- ENS LTJG LT LCDR CDR CAPT RADM GS-9 GS-11 GS-13 GS-14 GS-15 Other       8. Would you like to participate in our Mentoring program?   Yes, as a mentor   Yes, as a mentee   No, I am not interested       9. If you would like to participate in our Mentoring program, please BRIEFLY describe your career path goal.         10. Do you authorize APAOC to post your contact information to the APAOC website?*   Yes No

Last modified 06/20/2005 Copyright APAOC.ORG