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HHS University

HHS University
Phone: 301-451-6810
FAX: 301-480-3287

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of The Assistant Secretary For Administration and Management

Name of Training:

Course Number:

Date(s):

to:

Location of Training:

Name of Participant:

Agency/OPDIV (Please circle one):

ACF

AHRQ

AoA

CDC

CMS

FDA

HRSA

IHS

NIH

PSC

SAMHSA

Other Agency:

Telephone Number:

Fax Number:

E-mail Address:

Note: Attach trainee list (with above information) for group.

PAYMENT BY CREDIT CARD

Amount of Payment:

$

Government Credit Card Only (circle one):

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Credit Card Number:

Expiration Date:

Cardholder Name:

Phone:

Cardholder Address:

City/State:

Zip:

Cardholder Signature:

Date:

FOR OFFICE USE ONLY

Date Received:

Payment Amount:

Date Billed:

Last revised: July 19, 2006