DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Services Commissioned Corps
Division of Commissioned Corps Personnel and Readiness
Assignments and Career Management Branch/Assignments
1101 Wootton Parkway
Plaza Level, Suite 100
Rockville, MD 20852
Order Pursuant To Basic Training Contract
To Date
Order Number Contract Number
Appropriation Symbol
Object Class
Obligation Number
Estimated Cost
Part 1 This will certify that
is to be enrolled at your institution, subject to your acceptance
of him/her as a student, in accordance with the contract cited in the upper right corner of this order for the following course of
instruction:
beginning and ending .
Part 2 It is requested that after this student is enrolled, you execute Part 4 of this order. Retain 1 photocopy, and return the original
and 4 photocopies as soon as practicable to the undersigned.
Part 3 The terms and conditions of the contract cited in the upper right corner of this order shall govern.
Signature of Authorizing Official Name and Title
FUNDS ARE AVAILABLE. INVOICES WILL BE FORWARDED BY THE CONTRACTING OFFICE TO THE AGENCY
FINANCE OFFICE.
ADDRESS TO WHICH THIS ORDER IS TO BE RETURNED
Part 4
TO:
Date of enrollment
The student named above has been enrolled at this institution for the course of instruction listed in Part 1 of this order
(Note exception below.)
The curriculum to be pursued by this student, and the itemized charges due or to become due on account of such
enrollment for each semester or other period of instruction, are as follows:
It is certified that these charges are not greater than those charged to other students pursuing the same or similar curriculum.
Name of Institution
City
State
Zip Code
Signature Name and Title
PHS-1881-2
(Rev. 08/16)
DISTRIBUTION: Sponsoring Program; Accounting Point and Training Institution
PSC Publishing Services (301) 443-6740
EF
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