AEROMEDICAL PSYCHOLOGY TRAINING COURSE

DATA SHEET

Dean, USASAM
ATTN: MCCS-HAE
301 Dustoff Avenue
Fort Rucker, Alabama 36362
FAX: (334) 255-7084 (DSN 558-7084)
NAME: (Last, First, MI)
SSN:

DOB:

Military Component:

Branch:

RANK:

MS

MC

DOR
USA
USAF
USN
DoDCIV
CONT
BSC

USCG

OTHER

USMC

USAR

USARNG

MOS/AOC/AFSC:

EMAIL ADDRESS
MAILING ADDRESS:
WORK PHONE: DSN:

COMM

FAX:

HOME/CELL:
DUTY ASSIGNMENT AND UNIT ADDRESS:

CHECK APPLICABLE AREAS:

Licensed

Ph.D.

Psy.D.

____Other Professional Degree (Specify

____ABD (Dissertation defense scheduled date:

Please describe the aviation assets you will be supporting or how you might use this course in
your job upon completion: