Commissioned Corps of the U.S. Public Health Service American Indian/Alaska Native Commissioned Officers Advisory Committee (AI/ANCOAC) AI/ANCOAC Coin Order Form

Rank/Name	___________________________________________________________
Agency	___________________________________________________________
Address	___________________________________________________________
City	___________________________ State ___________ Zip ____________
Phone	___________________________________________________________
E-mail	___________________________________________________________
Number of Coins	_________________ Total _________________

Please Note: Coins are $10 each.

(Front)                                                      (Back)

Please print form and mail or deliver to:

CDR John M. Coleman Director, Pharmacy Services Santa Fe Indian Hospital 1700 Cerrillos Road Santa Fe, NM 87505 E-mail: john.coleman@ihs.gov

Make check/money order payable to: AI/AN Commissioned Officers Advisory Committee

 

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