Application form for naval postgraduate dental school correspondence courses and videotapes



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APPLICATION FORM FOR NAVAL POSTGRADUATE DENTAL SCHOOL

CORRESPONDENCE COURSES AND VIDEOTAPES
1. Fill in items A through K below.

2. All relevant items must be completed or the application will be returned.

3. Send the completed application to: Dean (NPDS 11A), Naval Postgraduate Dental School, 8901 Wisconsin Ave., Bethesda, MD 20889-5602

4. You may fax your application to (301) 295-5767 or DSN 295-5767 or send the information by email to patrick.w.mcmahon.civ@health.mil.

5. If you do not receive course materials within a reasonable time, please telephone DSN 285-4832 or (301) 319-4832 send email to patrick.w.mcmahon.civ@health.mil.

6. I understand that if I am not making satisfactory progress within six (6) months I will be terminated as a student and will be expected to immediately, upon notification, return the text, or other materials, to the Naval Postgraduate Dental School.


PRIVACY ACT STATEMENT: Under the authority of Title 5 USC 301, information regarding your military or other DOD status is requested in order to evaluate individual applications for enrollment in the Naval Correspondence Course program. The information will also be used to process course completion letters and to construct and maintain an official and continuing manual and/or automated record of correspondence course participation. The cumulative course participation record will not be divulged, without written authorization, to anyone other than those within the DOD for official use in determining performance and effecting organizational and administrative management. The transmittal of pertinent information to persons/institutions of the individual’s selection may be effected by a signed statement by the individual concerned. Completion of this form is voluntary; however, failure to provide the required information will result in an inability to process this application.
LOAN AGREEMENT (for videotapes): It is understood that these are US Government films and in consideration of the privilege to borrow them free of charge it is agreed that (1) they will not be cut or in any way altered; (2) they will not be shown where a viewing admission is charged; (3) no part of them will be duplicated; (4) they will be returned promptly to this activity, postage prepaid (library rate must be used).



A. Last name, First, MI:



B. Course (1st choice):


C. Rank/Rate


D. Leave Blank

(2nd choice):







E. Branch of service


F. Date

Assignment #

Grade/date



Remarks

G. Home address



1______________

2______________

3______________

4______________

5______________

6______________






H. Duty station address

7______________

8______________

9______________

10








J. AGD#:




Signature:




K. Phone #:










Email address:

Average:

Book/tape #:

I. Do you have a copy of the text?

Completion ltr sent:

Materials sent:

YES NO




Materials Ret’d:


11


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