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<td colspan="13"><h3
id="department-of-health-and-human-services">DEPARTMENT OF HEALTH AND
HUMAN SERVICES</h3>
<p>Commissioned Corps of the U.S. Public Health Service</p></td>
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<td colspan="10"><h6 id="order-pursuant-to-basic-training-contract">
ORDER PURSUANT TO BASIC TRAINING CONTRACT</h6></td>
<td colspan="3"><p>DATE</p>
<p>     </p></td>
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<td colspan="6" rowspan="3">TO:      </td>
<td colspan="2"><p>ORDER NO</p>
<p>     </p></td>
<td><p>TO</p>
<p>     </p></td>
<td colspan="4"><p>CONTRACT NO.</p>
<p>     </p></td>
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<td colspan="5"><p>APPROPRIATION SYMBOL</p>
<p>     </p></td>
<td colspan="2"><p>OBJECT CLASS</p>
<p>     </p></td>
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<td colspan="5"><p>OBLIGATION NUMBER</p>
<p>     </p></td>
<td colspan="2"><p>ESTIMATED COST</p>
<p>     </p></td>
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<tr class="even">
<td colspan="2"><blockquote>
<p><strong>Part 1</strong> This will certify that</p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="6">is to be enrolled at your institution,</td>
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<td colspan="13"><blockquote>
<p>subject to your acceptance of him/her as a student, in accordance
with the contract cited in the upper right corner of this</p>
</blockquote></td>
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<td colspan="4"><blockquote>
<p>order for the following course of instruction:</p>
</blockquote></td>
<td colspan="8">     </td>
<td></td>
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<td><blockquote>
<p>beginning</p>
</blockquote></td>
<td colspan="2">8/1/    </td>
<td colspan="2">and ending</td>
<td colspan="2">7/31/    </td>
<td colspan="6">.</td>
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<tr class="even">
<td colspan="13"><blockquote>
<p><strong>Part 2</strong> It is requested that after this student is
enrolled, you execute Part 4 of this order. Retain 1 photocopy,
and<br />
return the original and 4 photocopies as soon as practicable to the
undersigned.</p>
<p><strong>Part 3</strong> The terms and conditions of the contract
cited in the upper right corner of this order shall govern.</p>
<p><em>(SIGNATURE OF AUTHORIZING OFFICIAL)</em></p>
<p><u>     </u></p>
<p><em>(NAME AND TITLE PLEASE TYPE)</em></p>
<p>FUNDS ARE AVAILABLE. INVOICES WILL BE FORWARDED BY THE
CONTRACTING</p>
<p>OFFICE TO THE AGENCY FINANCE OFFICE.</p>
</blockquote></td>
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<td colspan="13"><blockquote>
<p>ADDRESS TO WHICH THIS ORDER IS TO BE RETURNED</p>
<p><strong>Part 4</strong> TO: <u>Agency Finance Office</u></p>
<p><u>     </u></p>
<p><u>     </u></p>
<p><u>     </u></p>
<p><u>     </u> <u>     </u></p>
<p><em>(Date of enrollment)</em></p>
<p>The student named above has been enrolled at this institution for the
course of instruction listed in Part 1 of<br />
this order (Note <em>exception</em> below.)</p>
</blockquote></td>
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<td colspan="13"><blockquote>
<p>The curriculum to be pursued by this student, and the itemized
charges due or to become due on account of<br />
such enrollment for each semester or other period of instruction, are as
follows:<br />
     </p>
</blockquote></td>
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<td colspan="13"><blockquote>
<p>It is certified that these charges are not greater than those charged
for other students pursuing the same or<br />
similar curriculum.</p>
<p><u>     </u></p>
</blockquote>
<p><em>(NAME OF INSTITUTION) (SIGNATURE)</em></p>
<blockquote>
<p><u>     </u> <u>     </u></p>
</blockquote>
<p><em>(CITY-STATE-ZIP CODE) (TYPE NAME AND TITLE)</em></p></td>
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