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_______________________________________________________________
City__________________________________________________________State____Zip__________
Address__________________________________________________________________________
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
John.coleman@ihs.gov
For a description of the coin logo, please visit http://www.aiancoac.freeservers.com/whats_new.html