+------+------+----------+---+-------+------+---------+----------------+---+
| **   |      |          |   |       |      |         |                |   |
| U.S. |      |          |   |       |      |         |                |   |
| De   |      |          |   |       |      |         |                |   |
| part |      |          |   |       |      |         |                |   |
| ment |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| H    |      |          |   |       |      |         |                |   |
| uman |      |          |   |       |      |         |                |   |
| Se   |      |          |   |       |      |         |                |   |
| rvic |      |          |   |       |      |         |                |   |
| es** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Of   |      |          |   |       |      |         |                |   |
| fice |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| Op   |      |          |   |       |      |         |                |   |
| erat |      |          |   |       |      |         |                |   |
| ions |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Divi |      |          |   |       |      |         |                |   |
| sion |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| Rec  |      |          |   |       |      |         |                |   |
| ruit |      |          |   |       |      |         |                |   |
| ment |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| 1101 |      |          |   |       |      |         |                |   |
| Woo  |      |          |   |       |      |         |                |   |
| tton |      |          |   |       |      |         |                |   |
| Park |      |          |   |       |      |         |                |   |
| way, |      |          |   |       |      |         |                |   |
| P    |      |          |   |       |      |         |                |   |
| laza |      |          |   |       |      |         |                |   |
| Le   |      |          |   |       |      |         |                |   |
| vel, |      |          |   |       |      |         |                |   |
| S    |      |          |   |       |      |         |                |   |
| uite |      |          |   |       |      |         |                |   |
| 100  |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ro   |      |          |   |       |      |         |                |   |
| ckvi |      |          |   |       |      |         |                |   |
| lle, |      |          |   |       |      |         |                |   |
| MD   |      |          |   |       |      |         |                |   |
| 2    |      |          |   |       |      |         |                |   |
| 0852 |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ph   |      |          |   |       |      |         |                |   |
| one: |      |          |   |       |      |         |                |   |
| (    |      |          |   |       |      |         |                |   |
| 240) |      |          |   |       |      |         |                |   |
| 453- |      |          |   |       |      |         |                |   |
| 6135 |      |          |   |       |      |         |                |   |
| --   |      |          |   |       |      |         |                |   |
| Fax: |      |          |   |       |      |         |                |   |
| (    |      |          |   |       |      |         |                |   |
| 240) |      |          |   |       |      |         |                |   |
| 453- |      |          |   |       |      |         |                |   |
| 6127 |      |          |   |       |      |         |                |   |
| --   |      |          |   |       |      |         |                |   |
| Em   |      |          |   |       |      |         |                |   |
| ail: |      |          |   |       |      |         |                |   |
| ARP  |      |          |   |       |      |         |                |   |
| @hhs |      |          |   |       |      |         |                |   |
| .gov |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **   |      |          |   |       |      |         |                |   |
| COMM |      |          |   |       |      |         |                |   |
| ISSI |      |          |   |       |      |         |                |   |
| ONED |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| ORPS |      |          |   |       |      |         |                |   |
| OF   |      |          |   |       |      |         |                |   |
| THE  |      |          |   |       |      |         |                |   |
| U.S. |      |          |   |       |      |         |                |   |
| PU   |      |          |   |       |      |         |                |   |
| BLIC |      |          |   |       |      |         |                |   |
| HE   |      |          |   |       |      |         |                |   |
| ALTH |      |          |   |       |      |         |                |   |
| S    |      |          |   |       |      |         |                |   |
| ERVI |      |          |   |       |      |         |                |   |
| CE** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| **A  |      |          |   |       |      |         |                |   |
| SSOC |      |          |   |       |      |         |                |   |
| IATE |      |          |   |       |      |         |                |   |
| R    |      |          |   |       |      |         |                |   |
| ECRU |      |          |   |       |      |         |                |   |
| ITER |      |          |   |       |      |         |                |   |
| EN   |      |          |   |       |      |         |                |   |
| ROLL |      |          |   |       |      |         |                |   |
| MENT |      |          |   |       |      |         |                |   |
| R    |      |          |   |       |      |         |                |   |
| EQUE |      |          |   |       |      |         |                |   |
| ST** |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| *Su  |      |          |   |       |      |         |                |   |
| bmit |      |          |   |       |      |         |                |   |
| c    |      |          |   |       |      |         |                |   |
| ompl |      |          |   |       |      |         |                |   |
| eted |      |          |   |       |      |         |                |   |
| form |      |          |   |       |      |         |                |   |
| to:* |      |          |   |       |      |         |                |   |
| **Of |      |          |   |       |      |         |                |   |
| fice |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| Oper |      |          |   |       |      |         |                |   |
| atio |      |          |   |       |      |         |                |   |
| ns** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| **A  |      |          |   |       |      |         |                |   |
| TTN: |      |          |   |       |      |         |                |   |
| Divi |      |          |   |       |      |         |                |   |
| sion |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| R    |      |          |   |       |      |         |                |   |
| ecru |      |          |   |       |      |         |                |   |
| itme |      |          |   |       |      |         |                |   |
| nt** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| **   |      |          |   |       |      |         |                |   |
| 1101 |      |          |   |       |      |         |                |   |
| Woo  |      |          |   |       |      |         |                |   |
| tton |      |          |   |       |      |         |                |   |
| Park |      |          |   |       |      |         |                |   |
| way, |      |          |   |       |      |         |                |   |
| P    |      |          |   |       |      |         |                |   |
| laza |      |          |   |       |      |         |                |   |
| Le   |      |          |   |       |      |         |                |   |
| vel, |      |          |   |       |      |         |                |   |
| S    |      |          |   |       |      |         |                |   |
| uite |      |          |   |       |      |         |                |   |
| 1    |      |          |   |       |      |         |                |   |
| 00** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| **Ro |      |          |   |       |      |         |                |   |
| ckvi |      |          |   |       |      |         |                |   |
| lle, |      |          |   |       |      |         |                |   |
| MD   |      |          |   |       |      |         |                |   |
| 208  |      |          |   |       |      |         |                |   |
| 52** |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| This |      |          |   |       |      |         |                |   |
| form |      |          |   |       |      |         |                |   |
| is   |      |          |   |       |      |         |                |   |
| to   |      |          |   |       |      |         |                |   |
| be   |      |          |   |       |      |         |                |   |
| s    |      |          |   |       |      |         |                |   |
| ubmi |      |          |   |       |      |         |                |   |
| tted |      |          |   |       |      |         |                |   |
| to   |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| Divi |      |          |   |       |      |         |                |   |
| sion |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| Rec  |      |          |   |       |      |         |                |   |
| ruit |      |          |   |       |      |         |                |   |
| ment |      |          |   |       |      |         |                |   |
| a    |      |          |   |       |      |         |                |   |
| long |      |          |   |       |      |         |                |   |
| with |      |          |   |       |      |         |                |   |
| two  |      |          |   |       |      |         |                |   |
| c    |      |          |   |       |      |         |                |   |
| ompl |      |          |   |       |      |         |                |   |
| eted |      |          |   |       |      |         |                |   |
| peer |      |          |   |       |      |         |                |   |
| re   |      |          |   |       |      |         |                |   |
| fere |      |          |   |       |      |         |                |   |
| nces |      |          |   |       |      |         |                |   |
| (u   |      |          |   |       |      |         |                |   |
| sing |      |          |   |       |      |         |                |   |
| form |      |          |   |       |      |         |                |   |
| P    |      |          |   |       |      |         |                |   |
| HS-7 |      |          |   |       |      |         |                |   |
| 051, |      |          |   |       |      |         |                |   |
| "R   |      |          |   |       |      |         |                |   |
| efer |      |          |   |       |      |         |                |   |
| ence |      |          |   |       |      |         |                |   |
| Req  |      |          |   |       |      |         |                |   |
| uest |      |          |   |       |      |         |                |   |
| for  |      |          |   |       |      |         |                |   |
| Ap   |      |          |   |       |      |         |                |   |
| plic |      |          |   |       |      |         |                |   |
| ants |      |          |   |       |      |         |                |   |
| to   |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| A    |      |          |   |       |      |         |                |   |
| ssoc |      |          |   |       |      |         |                |   |
| iate |      |          |   |       |      |         |                |   |
| R    |      |          |   |       |      |         |                |   |
| ecru |      |          |   |       |      |         |                |   |
| iter |      |          |   |       |      |         |                |   |
| Pro  |      |          |   |       |      |         |                |   |
| gram |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| U.S. |      |          |   |       |      |         |                |   |
| Pu   |      |          |   |       |      |         |                |   |
| blic |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| S    |      |          |   |       |      |         |                |   |
| ervi |      |          |   |       |      |         |                |   |
| ce") |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| a    |      |          |   |       |      |         |                |   |
| sup  |      |          |   |       |      |         |                |   |
| ervi |      |          |   |       |      |         |                |   |
| sory |      |          |   |       |      |         |                |   |
| r    |      |          |   |       |      |         |                |   |
| efer |      |          |   |       |      |         |                |   |
| ence |      |          |   |       |      |         |                |   |
| (    |      |          |   |       |      |         |                |   |
| also |      |          |   |       |      |         |                |   |
| u    |      |          |   |       |      |         |                |   |
| sing |      |          |   |       |      |         |                |   |
| form |      |          |   |       |      |         |                |   |
| PH   |      |          |   |       |      |         |                |   |
| S-70 |      |          |   |       |      |         |                |   |
| 51). |      |          |   |       |      |         |                |   |
| In   |      |          |   |       |      |         |                |   |
| comp |      |          |   |       |      |         |                |   |
| lete |      |          |   |       |      |         |                |   |
| pack |      |          |   |       |      |         |                |   |
| ages |      |          |   |       |      |         |                |   |
| will |      |          |   |       |      |         |                |   |
| not  |      |          |   |       |      |         |                |   |
| be   |      |          |   |       |      |         |                |   |
| pr   |      |          |   |       |      |         |                |   |
| oces |      |          |   |       |      |         |                |   |
| sed. |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **   |      |          |   |       | *    |         | **PHS Serial   |   |
| Appl |      |          |   |       | *Ran |         | Number:**      |   |
| ican |      |          |   |       | k:** |         |                |   |
| t\'s |      |          |   |       |      |         |                |   |
| Na   |      |          |   |       |      |         |                |   |
| me** |      |          |   |       |      |         |                |   |
| *(L  |      |          |   |       |      |         |                |   |
| ast, |      |          |   |       |      |         |                |   |
| Fi   |      |          |   |       |      |         |                |   |
| rst, |      |          |   |       |      |         |                |   |
| MI)  |      |          |   |       |      |         |                |   |
| (P   |      |          |   |       |      |         |                |   |
| rint |      |          |   |       |      |         |                |   |
| or   |      |          |   |       |      |         |                |   |
| Typ  |      |          |   |       |      |         |                |   |
| e)** |      |          |   |       |      |         |                |   |
| *:** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| *    |      |          | * |       |      |         |                |   |
| *Cat |      |          | * |       |      |         |                |   |
| egor |      |          | E |       |      |         |                |   |
| y:** |      |          | - |       |      |         |                |   |
|      |      |          | m |       |      |         |                |   |
|      |      |          | a |       |      |         |                |   |
|      |      |          | i |       |      |         |                |   |
|      |      |          | l |       |      |         |                |   |
|      |      |          | A |       |      |         |                |   |
|      |      |          | d |       |      |         |                |   |
|      |      |          | d |       |      |         |                |   |
|      |      |          | r |       |      |         |                |   |
|      |      |          | e |       |      |         |                |   |
|      |      |          | s |       |      |         |                |   |
|      |      |          | s |       |      |         |                |   |
|      |      |          | : |       |      |         |                |   |
|      |      |          | * |       |      |         |                |   |
|      |      |          | * |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **   |      |          |   |       | **P  |         |                |   |
| Work |      |          |   |       | hone |         |                |   |
| or   |      |          |   |       | No   |         |                |   |
| Home |      |          |   |       | .:** |         |                |   |
| Ad   |      |          |   |       |      |         |                |   |
| dres |      |          |   |       |      |         |                |   |
| s:** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
|      |      |          |   |       | *    |         |                |   |
|      |      |          |   |       | *FAX |         |                |   |
|      |      |          |   |       | No   |         |                |   |
|      |      |          |   |       | .:** |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **S  |      |          |   |       |      |         |                |   |
| tatu |      |          |   |       |      |         |                |   |
| s:** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ac   |      |          |   |       |      |         |                |   |
| tive |      |          |   |       |      |         |                |   |
| Duty |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| Off  |      |          |   |       |      |         |                |   |
| icer |      |          |   |       |      |         |                |   |
| Ac   |      |          |   |       |      |         |                |   |
| tive |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| ivil |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ret  |      |          |   |       |      |         |                |   |
| ired |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| Off  |      |          |   |       |      |         |                |   |
| icer |      |          |   |       |      |         |                |   |
| Ret  |      |          |   |       |      |         |                |   |
| ired |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| ivil |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
| Inac |      |          |   |       |      |         |                |   |
| tive |      |          |   |       |      |         |                |   |
| Res  |      |          |   |       |      |         |                |   |
| erve |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| Off  |      |          |   |       |      |         |                |   |
| icer |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ju   |      |          |   |       |      |         |                |   |
| nior |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| Off  |      |          |   |       |      |         |                |   |
| icer |      |          |   |       |      |         |                |   |
| Stu  |      |          |   |       |      |         |                |   |
| dent |      |          |   |       |      |         |                |   |
| Trai |      |          |   |       |      |         |                |   |
| ning |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Ex   |      |          |   |       |      |         |                |   |
| tern |      |          |   |       |      |         |                |   |
| Pro  |      |          |   |       |      |         |                |   |
| gram |      |          |   |       |      |         |                |   |
| (COS |      |          |   |       |      |         |                |   |
| TEP) |      |          |   |       |      |         |                |   |
| Par  |      |          |   |       |      |         |                |   |
| tici |      |          |   |       |      |         |                |   |
| pant |      |          |   |       |      |         |                |   |
| Se   |      |          |   |       |      |         |                |   |
| nior |      |          |   |       |      |         |                |   |
| CO   |      |          |   |       |      |         |                |   |
| STEP |      |          |   |       |      |         |                |   |
| Par  |      |          |   |       |      |         |                |   |
| tici |      |          |   |       |      |         |                |   |
| pant |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **De |      |          |   |       |      |         |                |   |
| part |      |          |   |       |      |         |                |   |
| ment |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| H    |      |          |   |       |      |         |                |   |
| uman |      |          |   |       |      |         |                |   |
| Serv |      |          |   |       |      |         |                |   |
| ices |      |          |   |       |      |         |                |   |
| (    |      |          |   |       |      |         |                |   |
| HHS) |      |          |   |       |      |         |                |   |
| /non |      |          |   |       |      |         |                |   |
| -HHS |      |          |   |       |      |         |                |   |
| orga |      |          |   |       |      |         |                |   |
| niza |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| affi |      |          |   |       |      |         |                |   |
| liat |      |          |   |       |      |         |                |   |
| ion, |      |          |   |       |      |         |                |   |
| if   |      |          |   |       |      |         |                |   |
| Fed  |      |          |   |       |      |         |                |   |
| eral |      |          |   |       |      |         |                |   |
| emp  |      |          |   |       |      |         |                |   |
| loye |      |          |   |       |      |         |                |   |
| e:** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ag   |      |          |   |       |      |         |                |   |
| ency |      |          |   |       |      |         |                |   |
| for  |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| care |      |          |   |       |      |         |                |   |
| Rese |      |          |   |       |      |         |                |   |
| arch |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Qua  |      |          |   |       |      |         |                |   |
| lity |      |          |   |       |      |         |                |   |
| Ag   |      |          |   |       |      |         |                |   |
| ency |      |          |   |       |      |         |                |   |
| for  |      |          |   |       |      |         |                |   |
| T    |      |          |   |       |      |         |                |   |
| oxic |      |          |   |       |      |         |                |   |
| Su   |      |          |   |       |      |         |                |   |
| bsta |      |          |   |       |      |         |                |   |
| nces |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Dis  |      |          |   |       |      |         |                |   |
| ease |      |          |   |       |      |         |                |   |
| Regi |      |          |   |       |      |         |                |   |
| stry |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Cen  |      |          |   |       |      |         |                |   |
| ters |      |          |   |       |      |         |                |   |
| for  |      |          |   |       |      |         |                |   |
| Dis  |      |          |   |       |      |         |                |   |
| ease |      |          |   |       |      |         |                |   |
| Con  |      |          |   |       |      |         |                |   |
| trol |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Pr   |      |          |   |       |      |         |                |   |
| even |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| Cen  |      |          |   |       |      |         |                |   |
| ters |      |          |   |       |      |         |                |   |
| for  |      |          |   |       |      |         |                |   |
| Medi |      |          |   |       |      |         |                |   |
| care |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Medi |      |          |   |       |      |         |                |   |
| caid |      |          |   |       |      |         |                |   |
| Serv |      |          |   |       |      |         |                |   |
| ices |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Food |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Drug |      |          |   |       |      |         |                |   |
| Ad   |      |          |   |       |      |         |                |   |
| mini |      |          |   |       |      |         |                |   |
| stra |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| R    |      |          |   |       |      |         |                |   |
| esou |      |          |   |       |      |         |                |   |
| rces |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Serv |      |          |   |       |      |         |                |   |
| ices |      |          |   |       |      |         |                |   |
| Ad   |      |          |   |       |      |         |                |   |
| mini |      |          |   |       |      |         |                |   |
| stra |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| (H   |      |          |   |       |      |         |                |   |
| RSA) |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| HR   |      |          |   |       |      |         |                |   |
| SA/B |      |          |   |       |      |         |                |   |
| PHC/ |      |          |   |       |      |         |                |   |
| Divi |      |          |   |       |      |         |                |   |
| sion |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Imm  |      |          |   |       |      |         |                |   |
| igra |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
| s/De |      |          |   |       |      |         |                |   |
| part |      |          |   |       |      |         |                |   |
| ment |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Home |      |          |   |       |      |         |                |   |
| land |      |          |   |       |      |         |                |   |
| Secu |      |          |   |       |      |         |                |   |
| rity |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| In   |      |          |   |       |      |         |                |   |
| dian |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
| Nati |      |          |   |       |      |         |                |   |
| onal |      |          |   |       |      |         |                |   |
| In   |      |          |   |       |      |         |                |   |
| stit |      |          |   |       |      |         |                |   |
| utes |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| S    |      |          |   |       |      |         |                |   |
| ubst |      |          |   |       |      |         |                |   |
| ance |      |          |   |       |      |         |                |   |
| A    |      |          |   |       |      |         |                |   |
| buse |      |          |   |       |      |         |                |   |
| and  |      |          |   |       |      |         |                |   |
| Me   |      |          |   |       |      |         |                |   |
| ntal |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| Serv |      |          |   |       |      |         |                |   |
| ices |      |          |   |       |      |         |                |   |
| Ad   |      |          |   |       |      |         |                |   |
| mini |      |          |   |       |      |         |                |   |
| stra |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| E    |      |          |   |       |      |         |                |   |
| nvir |      |          |   |       |      |         |                |   |
| onme |      |          |   |       |      |         |                |   |
| ntal |      |          |   |       |      |         |                |   |
| Pr   |      |          |   |       |      |         |                |   |
| otec |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| Ag   |      |          |   |       |      |         |                |   |
| ency |      |          |   |       |      |         |                |   |
| Fed  |      |          |   |       |      |         |                |   |
| eral |      |          |   |       |      |         |                |   |
| Bu   |      |          |   |       |      |         |                |   |
| reau |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| Pri  |      |          |   |       |      |         |                |   |
| sons |      |          |   |       |      |         |                |   |
| U.S. |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| oast |      |          |   |       |      |         |                |   |
| G    |      |          |   |       |      |         |                |   |
| uard |      |          |   |       |      |         |                |   |
| U.S. |      |          |   |       |      |         |                |   |
| Mars |      |          |   |       |      |         |                |   |
| hals |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
| Ot   |      |          |   |       |      |         |                |   |
| her: |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **S  |      |          |   |       |      |         |                |   |
| choo |      |          |   |       |      |         |                |   |
| l/Un |      |          |   |       |      |         |                |   |
| iver |      |          |   |       |      |         |                |   |
| sity |      |          |   |       |      |         |                |   |
| from |      |          |   |       |      |         |                |   |
| w    |      |          |   |       |      |         |                |   |
| hich |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| fice |      |          |   |       |      |         |                |   |
| r\'s |      |          |   |       |      |         |                |   |
| qu   |      |          |   |       |      |         |                |   |
| alif |      |          |   |       |      |         |                |   |
| ying |      |          |   |       |      |         |                |   |
| de   |      |          |   |       |      |         |                |   |
| gree |      |          |   |       |      |         |                |   |
| for  |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| Comm |      |          |   |       |      |         |                |   |
| issi |      |          |   |       |      |         |                |   |
| oned |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| U.S. |      |          |   |       |      |         |                |   |
| Pu   |      |          |   |       |      |         |                |   |
| blic |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
| (Co  |      |          |   |       |      |         |                |   |
| rps) |      |          |   |       |      |         |                |   |
| was  |      |          |   |       |      |         |                |   |
| obt  |      |          |   |       |      |         |                |   |
| aine |      |          |   |       |      |         |                |   |
| d:** |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **I  |      |          |   |       |      |         |                |   |
| cer  |      |          |   |       |      |         |                |   |
| tify |      |          |   |       |      |         |                |   |
| that |      |          |   |       |      |         |                |   |
| I    |      |          |   |       |      |         |                |   |
| own  |      |          |   |       |      |         |                |   |
| at   |      |          |   |       |      |         |                |   |
| l    |      |          |   |       |      |         |                |   |
| east |      |          |   |       |      |         |                |   |
| one  |      |          |   |       |      |         |                |   |
| comp |      |          |   |       |      |         |                |   |
| lete |      |          |   |       |      |         |                |   |
| set  |      |          |   |       |      |         |                |   |
| of   |      |          |   |       |      |         |                |   |
| the  |      |          |   |       |      |         |                |   |
| Pu   |      |          |   |       |      |         |                |   |
| blic |      |          |   |       |      |         |                |   |
| He   |      |          |   |       |      |         |                |   |
| alth |      |          |   |       |      |         |                |   |
| Ser  |      |          |   |       |      |         |                |   |
| vice |      |          |   |       |      |         |                |   |
| un   |      |          |   |       |      |         |                |   |
| ifor |      |          |   |       |      |         |                |   |
| m.** |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| Yes  |      | Initial  |   | Date  |      | **      |                |   |
| No   |      |          |   |       |      | Note:** |                |   |
|      |      |          |   |       |      | The     |                |   |
|      |      |          |   |       |      | Service |                |   |
|      |      |          |   |       |      | Dress   |                |   |
|      |      |          |   |       |      | Blue    |                |   |
|      |      |          |   |       |      | uniform |                |   |
|      |      |          |   |       |      | is      |                |   |
|      |      |          |   |       |      | reco    |                |   |
|      |      |          |   |       |      | mmended |                |   |
|      |      |          |   |       |      | for     |                |   |
|      |      |          |   |       |      | wear by |                |   |
|      |      |          |   |       |      | Corps   |                |   |
|      |      |          |   |       |      | o       |                |   |
|      |      |          |   |       |      | fficers |                |   |
|      |      |          |   |       |      | during  |                |   |
|      |      |          |   |       |      | att     |                |   |
|      |      |          |   |       |      | endance |                |   |
|      |      |          |   |       |      | at      |                |   |
|      |      |          |   |       |      | recr    |                |   |
|      |      |          |   |       |      | uitment |                |   |
|      |      |          |   |       |      | fu      |                |   |
|      |      |          |   |       |      | nctions |                |   |
|      |      |          |   |       |      | and     |                |   |
|      |      |          |   |       |      | other   |                |   |
|      |      |          |   |       |      | fu      |                |   |
|      |      |          |   |       |      | nctions |                |   |
|      |      |          |   |       |      | pr      |                |   |
|      |      |          |   |       |      | omoting |                |   |
|      |      |          |   |       |      | the     |                |   |
|      |      |          |   |       |      | Corps.  |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| **I  |      |          |   |       |      |         |                |   |
| cer  |      |          |   |       |      |         |                |   |
| tify |      |          |   |       |      |         |                |   |
| that |      |          |   |       |      |         |                |   |
| I    |      |          |   |       |      |         |                |   |
| meet |      |          |   |       |      |         |                |   |
| cur  |      |          |   |       |      |         |                |   |
| rent |      |          |   |       |      |         |                |   |
| C    |      |          |   |       |      |         |                |   |
| orps |      |          |   |       |      |         |                |   |
| groo |      |          |   |       |      |         |                |   |
| ming |      |          |   |       |      |         |                |   |
| stan |      |          |   |       |      |         |                |   |
| dard |      |          |   |       |      |         |                |   |
| s.** |      |          |   |       |      |         |                |   |
| (See |      |          |   |       |      |         |                |   |
| *htt |      |          |   |       |      |         |                |   |
| p:// |      |          |   |       |      |         |                |   |
| dcp. |      |          |   |       |      |         |                |   |
| psc. |      |          |   |       |      |         |                |   |
| gov/ |      |          |   |       |      |         |                |   |
| pdf_ |      |          |   |       |      |         |                |   |
| docs |      |          |   |       |      |         |                |   |
| /pdf |      |          |   |       |      |         |                |   |
| _doc |      |          |   |       |      |         |                |   |
| s_26 |      |          |   |       |      |         |                |   |
| 31.p |      |          |   |       |      |         |                |   |
| df*, |      |          |   |       |      |         |                |   |
| Sec  |      |          |   |       |      |         |                |   |
| tion |      |          |   |       |      |         |                |   |
| E,   |      |          |   |       |      |         |                |   |
| \"Of |      |          |   |       |      |         |                |   |
| fice |      |          |   |       |      |         |                |   |
| rs\' |      |          |   |       |      |         |                |   |
| Ap   |      |          |   |       |      |         |                |   |
| pear |      |          |   |       |      |         |                |   |
| ance |      |          |   |       |      |         |                |   |
| \"). |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+
| Ini  |      | Date     |   |       |      |         |                |   |
| tial |      |          |   |       |      |         |                |   |
|      |      |          |   |       |      |         |                |   |
+------+------+----------+---+-------+------+---------+----------------+---+

+----------+----------+-----+-----+-----------+---------+---+-----------+
| **COMM   |          |     |     |           |         |   |           |
| ISSIONED |          |     |     |           |         |   |           |
| CORPS OF |          |     |     |           |         |   |           |
| THE U.S. |          |     |     |           |         |   |           |
| PUBLIC   |          |     |     |           |         |   |           |
| HEALTH   |          |     |     |           |         |   |           |
| S        |          |     |     |           |         |   |           |
| ERVICE** |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
| **A      |          |     |     |           |         |   |           |
| SSOCIATE |          |     |     |           |         |   |           |
| R        |          |     |     |           |         |   |           |
| ECRUITER |          |     |     |           |         |   |           |
| EN       |          |     |     |           |         |   |           |
| ROLLMENT |          |     |     |           |         |   |           |
| R        |          |     |     |           |         |   |           |
| EQUEST** |          |     |     |           |         |   |           |
| *(con    |          |     |     |           |         |   |           |
| tinued)* |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| **I      |          |     |     |           |         |   |           |
| have:**  |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| •        |          |     |     | •         |         |   |           |
| **       |          |     |     | **Earned  |         |   |           |
| Attended |          |     |     | the PHS   |         |   |           |
| the      |          |     |     | Com       |         |   |           |
| Basic    |          |     |     | missioned |         |   |           |
| Officer  |          |     |     | Corps     |         |   |           |
| Training |          |     |     | Training  |         |   |           |
| Course   |          |     |     | Ribbon.** |         |   |           |
| (        |          |     |     |           |         |   |           |
| BOTC).** |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| Yes No   | Initial  | D   |     | Yes No    | Initial |   | Date      |
|          |          | ate |     |           |         |   |           |
|          |          |     |     |           |         |   | **     ** |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| •        |          |     |     | • **Have  |         |   |           |
| **Succ   |          |     |     | an        |         |   |           |
| essfully |          |     |     | overall   |         |   |           |
| c        |          |     |     | \'D\'     |         |   |           |
| ompleted |          |     |     | Com       |         |   |           |
| the      |          |     |     | missioned |         |   |           |
| 3-year   |          |     |     | O         |         |   |           |
| prob     |          |     |     | fficers\' |         |   |           |
| ationary |          |     |     | Effe      |         |   |           |
| p        |          |     |     | ctiveness |         |   |           |
| eriod.** |          |     |     | Report**  |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     | *         |         |   |           |
|          |          |     |     | *score.** |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| Yes No   | Initial  | D   |     | Yes No    | Initial |   | Date      |
|          |          | ate |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| • **No   |          |     |     | • **Met   |         |   |           |
| current  |          |     |     | the Basic |         |   |           |
| or       |          |     |     | level of  |         |   |           |
| pending  |          |     |     | force     |         |   |           |
| disc     |          |     |     | readiness |         |   |           |
| iplinary |          |     |     | as        |         |   |           |
| ac       |          |     |     | currently |         |   |           |
| tions.** |          |     |     | d         |         |   |           |
|          |          |     |     | efined.** |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| Yes No   | Initial  | D   |     | Yes No    | Initial |   | Date      |
|          |          | ate |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| •        |          |     |     |           |         |   |           |
| **C      |          |     |     |           |         |   |           |
| ompleted |          |     |     |           |         |   |           |
| the      |          |     |     |           |         |   |           |
| intr     |          |     |     |           |         |   |           |
| oductory |          |     |     |           |         |   |           |
| A        |          |     |     |           |         |   |           |
| ssociate |          |     |     |           |         |   |           |
| R        |          |     |     |           |         |   |           |
| ecruiter |          |     |     |           |         |   |           |
| tra      |          |     |     |           |         |   |           |
| ining.** |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| Yes No   | Initial  | D   |     |           |         |   |           |
|          |          | ate |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| **S      |          |     |     |           |         |   |           |
| tatement |          |     |     |           |         |   |           |
| of       |          |     |     |           |         |   |           |
| Intent   |          |     |     |           |         |   |           |
| to Serve |          |     |     |           |         |   |           |
| in the   |          |     |     |           |         |   |           |
| A        |          |     |     |           |         |   |           |
| ssociate |          |     |     |           |         |   |           |
| R        |          |     |     |           |         |   |           |
| ecruiter |          |     |     |           |         |   |           |
| Pr       |          |     |     |           |         |   |           |
| ogram:** |          |     |     |           |         |   |           |
| *(       |          |     |     |           |         |   |           |
| Describe |          |     |     |           |         |   |           |
| below    |          |     |     |           |         |   |           |
| your     |          |     |     |           |         |   |           |
| goals,   |          |     |     |           |         |   |           |
| moti     |          |     |     |           |         |   |           |
| vations, |          |     |     |           |         |   |           |
| and/or   |          |     |     |           |         |   |           |
| purpose  |          |     |     |           |         |   |           |
| for      |          |     |     |           |         |   |           |
| joining  |          |     |     |           |         |   |           |
| the      |          |     |     |           |         |   |           |
| A        |          |     |     |           |         |   |           |
| ssociate |          |     |     |           |         |   |           |
| R        |          |     |     |           |         |   |           |
| ecruiter |          |     |     |           |         |   |           |
| Program. |          |     |     |           |         |   |           |
| Please   |          |     |     |           |         |   |           |
| attach   |          |     |     |           |         |   |           |
| an       |          |     |     |           |         |   |           |
| ad       |          |     |     |           |         |   |           |
| ditional |          |     |     |           |         |   |           |
| sheet if |          |     |     |           |         |   |           |
| nece     |          |     |     |           |         |   |           |
| ssary.)* |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| **Appl   |          |     |     |           |         | * |           |
| icant\'s |          |     |     |           |         | * |           |
| Sign     |          |     |     |           |         | D |           |
| ature:** |          |     |     |           |         | a |           |
|          |          |     |     |           |         | t |           |
|          |          |     |     |           |         | e |           |
|          |          |     |     |           |         | * |           |
|          |          |     |     |           |         | * |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| **SU     |          |     |     |           |         |   |           |
| PERVISOR |          |     |     |           |         |   |           |
| CONCU    |          |     |     |           |         |   |           |
| RRENCE** |          |     |     |           |         |   |           |
| (for     |          |     |     |           |         |   |           |
| Federal  |          |     |     |           |         |   |           |
| em       |          |     |     |           |         |   |           |
| ployees) |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+
| **Print  |          |     | **  |           |         | * |           |
| or Type  |          |     | Sig |           |         | * |           |
| Name:**  |          |     | nat |           |         | D |           |
|          |          |     | ure |           |         | a |           |
|          |          |     | :** |           |         | t |           |
|          |          |     |     |           |         | e |           |
|          |          |     |     |           |         | * |           |
|          |          |     |     |           |         | * |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
|          |          |     |     |           |         |   |           |
+----------+----------+-----+-----+-----------+---------+---+-----------+

+-----------------------------------+-----------------------+----------+
| **COMMISSIONED CORPS OF THE U.S.  |                       |          |
| PUBLIC HEALTH SERVICE**           |                       |          |
|                                   |                       |          |
| **ASSOCIATE RECRUITER ENROLLMENT  |                       |          |
| REQUEST** *(continued)*           |                       |          |
+-----------------------------------+-----------------------+----------+
| *Expected Volunteer Duties of     |                       |          |
| Associate Recruiters (ARs)*       |                       |          |
|                                   |                       |          |
| ARs inform colleagues and         |                       |          |
| students in healthcare,           |                       |          |
| engineering, and IT professions   |                       |          |
| about professional opportunities  |                       |          |
| available in the Commissioned     |                       |          |
| Corps of the U.S. Public Health   |                       |          |
| Service (Corps). Drawing on their |                       |          |
| career experiences in the Corps,  |                       |          |
| ARs make recruitment              |                       |          |
| presentations augmented by        |                       |          |
| printed and/or video materials on |                       |          |
| professional opportunities in the |                       |          |
| Corps. ARs should make every      |                       |          |
| effort to be preceptors in the    |                       |          |
| Commissioned Officer Student      |                       |          |
| Training and Extern Program,      |                       |          |
| internships, and rotations. ARs   |                       |          |
| should also pursue opportunities  |                       |          |
| to attend national or regional    |                       |          |
| student/professional conferences  |                       |          |
| and local schools/universities to |                       |          |
| provide information on career     |                       |          |
| opportunities to eligible         |                       |          |
| candidates.                       |                       |          |
|                                   |                       |          |
| ARs recruit whenever and wherever |                       |          |
| the opportunity presents itself.  |                       |          |
| For example, formal and informal  |                       |          |
| meetings with colleagues at work; |                       |          |
| professional associations;        |                       |          |
| residency programs; school and    |                       |          |
| business visits (e.g., Lions      |                       |          |
| Club, Rotary Club, Kiwanis, etc.) |                       |          |
| and social gatherings. The AR\'s  |                       |          |
| alma mater, alumni association,   |                       |          |
| or local colleges are some of the |                       |          |
| best places to start. If a        |                       |          |
| recruiting opportunity presents   |                       |          |
| itself at a college/university,   |                       |          |
| the ARs are responsible for       |                       |          |
| coordinating activities with the  |                       |          |
| faculty.                          |                       |          |
|                                   |                       |          |
| **ARs are encouraged and expected |                       |          |
| to recruit for not only the       |                       |          |
| Corps, but also for the Operating |                       |          |
| Divisions of the Department of    |                       |          |
| Health and Human Services (HHS)   |                       |          |
| or the non-HHS agencies to which  |                       |          |
| officers are assigned. These      |                       |          |
| recruitment activities help grow  |                       |          |
| the Corps and they also augment   |                       |          |
| the recruitment efforts of        |                       |          |
| HHS/non-HHS agencies and help to  |                       |          |
| meet staffing needs.**            |                       |          |
+-----------------------------------+-----------------------+----------+
| **SUPERVISOR CONCURRENCE**        |                       |          |
+-----------------------------------+-----------------------+----------+
| I concur with this application    |                       |          |
| and understand that any Associate |                       |          |
| Recruiter activities that occur   |                       |          |
| during normal duty hours must be  |                       |          |
| approved by me according to my    |                       |          |
| organization\'s applicable        |                       |          |
| policies.                         |                       |          |
+-----------------------------------+-----------------------+----------+
| **Supervisor\'s Name** *(Print or | **Supervisor\'s       |          |
| Type)*:                           | Title:**              |          |
|                                   |                       |          |
|                                   |                       |          |
+-----------------------------------+-----------------------+----------+
| **Supervisor\'s Signature:**      |                       | *        |
|                                   |                       | *Date:** |
|                                   |                       |          |
|                                   |                       |          |
+-----------------------------------+-----------------------+----------+
| **Privacy Act Statement**         |                       |          |
+-----------------------------------+-----------------------+----------+
| *Systems of Records:* 09-40-0001, |                       |          |
| "PHS Commissioned Corps General   |                       |          |
| Personnel Records," HHS/PSC/HRS.  |                       |          |
|                                   |                       |          |
| *General:* This statement is      |                       |          |
| provided pursuant to the Privacy  |                       |          |
| Act of 1974 (5 U.S.C. 552a).      |                       |          |
|                                   |                       |          |
| *Authority:* 42 U.S.C. 201 et     |                       |          |
| seq.; Executive Order 9397.       |                       |          |
|                                   |                       |          |
| *Purpose:* The Public Health      |                       |          |
| Service serial number is          |                       |          |
| requested for identification      |                       |          |
| purposes only and is used to      |                       |          |
| distinguish a record from those   |                       |          |
| of commissioned officers who may  |                       |          |
| have similar names and dates of   |                       |          |
| birth.                            |                       |          |
|                                   |                       |          |
| *Effects of Nondisclosure:*       |                       |          |
| Failure to supply complete and    |                       |          |
| accurate information may result   |                       |          |
| in delays and/or denial of        |                       |          |
| request.                          |                       |          |
+-----------------------------------+-----------------------+----------+