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Department of Health and Human Services
Commissioned Corps of the U.S. Public Health Service
American Indian / Alaska Native
Commissioned Officers Advisory Committee (AIANCOAC)

AIANCOAC Coin Order Form

Rank/Name_______________________________________________________________________ Department of Health and Human Services (HHS) Operating Division/Staff Division or non-HHS organization_______________________________________________________________
Phone number ____________________________E-mail___________________________________ Number of coins ________________  Total $__________________  

                         Coins are $10 each. Make check/money order payable to:
                             AI/AN Commissioned Officers Advisory Committee

Please print form and mail or deliver to:

CAPT John M. Coleman, USPHS
Director, Pharmacy Services
Santa Fe Indian Hospital
1700 Cerrillos Road Santa Fe, NM 87505

For a description of the coin logo, please visit http://www.aiancoac.freeservers.com/whats_new.html
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