Application for deployed military personnel.
(*)=Required

Abbreviated Form

Detailed Form

FULL NAME (LAST, FIRST, MIDDLE)*     DOB*     AGE*     RANK*     CURRENT UNIT (PERMANENT DUTY STATION)*     CURRENT UNIT ADDRESS*     SSN     DEPLOYED* Yes  No   Deployed Unit*     DEPLOYED LOCATION (ie Kuwait)*     MOS*     HOME ADDRESS*     SHIPPING ADDRESS IF APPLICABLE     EMAIL ADDRESS*     EMAIL ADDRESS     CONTACT COMMERCIAL PHONE*     DSN PHONE#*     I am a* MD DO PA RN LVN CRNA NCP RT PHD RD OTHER   If other, state     What is your specialty?*     Critical Care Certification?* Yes  No   What is your primary civilian practice? *     What is your primary practice on active duty?*     Are you currently in trainng?* Yes  No   I am currently* AD  Reserve  National Guard  Student  IMA   Are you a student at the AMEDD center and school?* Yes  No   Are you currently actively involved in the care of burn patients? * Yes No   I will be taking care of burn patient in the next 12 months. * Yes  No   Do you have a primary role in teaching? (25% or more of my time is spent teaching) * Yes  No   I teach (check all that apply)       RESIDENTS     MEDICAL STUDENTS     PHYSICIAN ASSISTANTS     NURSING STUDENTS     91D     SPECIAL OP FORCES     ROTC     RESPIRATORY STUDENTS     NUTRITION STUDENTS     DMRT     NONE OF THE ABOVE     I have a University teaching affiliation? * Yes  No   I would like to view my pdf through:* E-Mail  Web Access