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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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