DEPARTMENT OF HEALTH AND HUMAN SERVICES
Division of Commissioned Corps Personnel and Readiness (DCCPR)
Assignments and Career Management Branch/Assignments
1101 Wootton Parkway, Plaza Level, Suite 100
Rockville, MD 20852
Request for Basic Training Contract Memo
From Date
Name of Officer
Category
(Sponsoring Department of Health and Human Services (HHS) Operating Division (OPDIV)/Staff Division (STAFFDIV) or Non-HHS
Organization to which officers of the Commissioned Corps of the U.S. Public Health Service are detailed.)
To:
Division of Commissioned Corps Personnel and Readiness
Assignments and Career Management Branch/Assignments
1101 Wootton Parkway, Plaza Level, Suite 100
Rockville, MD 20852
A Basic Training Contract is needed for the subject officer from (Exact Date Training Starts)
through (Exact Date
Training Ends)
.
The subject officer is pursuing training in (Degree or Training Program)
which is outside of HHS. Payment is required by the sponsoring/requesting OPDIV/STAFFDIV or Non-HHS Organization to the
training institution.
The office that will affix the 'Institution Seal' to the contract is as follows: [NOTE: The officer can get this information from the
Bursar or Finance offices. The information below must be the address of the registrar.]
Name of Institution Department in Institution
Building and Room Number Street Address
City
State
Zip Code
University Contact Person
Name Title
Phone Number
Funds for this training will be obligated from Fiscal Year(s)
The officer has been informed that he/she must provide a copy of his/her grades (or other evidence of progress) to the sponsoring
program for review and for submission to DCCPR, upon request.
This information is provided by the program contact
Sponsoring OPDIV/STAFFDIV or Non-HHS Organization
Name
Address
Phone Number Fax Number
Email
Sponsoring Finance Office
Name
Address
Phone Number Fax Number
Email
(Rev. 1/17)
PSC Publishing Services (301) 443-6740
EF
