2017 Joint Civilian Orientation Conference Nomination Fo

2017 Joint Civilian Orientation Conference
Nomination Form

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PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE SUBMITTING THIS FORM
•

This form must be typed.

•

A one page biography must be submitted with this form.

• The 2017 JCOC is scheduled for the Summer of 2017. Participants are expected to attend the entire
conference.
• Nomination Deadline: Nominations must be received in the JCOC program office, no later than Friday,
January 6, 2017.
• Only completed nomination forms with biographies will be accepted. Letters of endorsement and
resumes will not be accepted.
• Individual forms should be emailed to: [email protected]. To ensure the form reaches the
program office, the subject line should read “JCOC 2017” and the nominee’s last name. For example:
“JCOC 2017: Smith.”
• DoD nominating authorities may combine all of their nominations under one group name in the subject
line. For example: “JCOC 2017: STRATCOM, JCOC 2017: Air Force, JCOC 2017: Doe.”
• All packages will be screened for eligibility. Announcements are expected by the week of January 16,
2017.
• Nominators will be informed of selection results and are responsible for notifying their nominees of
selection or non-selection.
• For any questions, please refer to our website: jcoc.osd.mil, or contact Caroline D. Wilson, at:
[email protected] or 703-695-2036.

Nominator's Full Name and Rank: (Nominations
from DoD officials or JCOC Alumni only)

Nominator's Organization: (Nominations from
DoD officials or JCOC Alumni only)

Nominator's Email Address:

Nominator's Phone Number:

Military/DoD Only: Indicate Title of Nominating Authority (SD, SecNav, CJCS, ASD, USD, etc.)

JCOC Alumni Only: Indicate Class (ex. JCOC 86):

Nominee's Information:
Title:
Mr.

Mrs.

Ms.

Last Name:

Dr.
First Name:

Middle Initial:

Position Title:

Organization/Company:

Work Email:

Personal Email:

Phone Number

Select One

Alt. Phone Number

Work

Work

Cell

Cell

Organization/Company Website:

Nominee's Alternate Point of Contact/Executive Assistant
Name:

Phone Number:

Select One

Email:

1. Is the nominee a U.S. Citizen? If not, nominee is ineligible for the JCOC program.
Yes
No
2. Does the nominee work for the U.S. Federal Government? If yes, nominee is ineligible for the JCOC program.
Yes
No
3. Is the nominee in good health? Capable of climbing eight flights of stairs or ladders, and enduring 12-14 hour
days?
Yes
No
4. Has the nominee served in the U.S. Armed Forces (active, guard or reserve duty) since 1990? If yes, nominee is
ineligible for the JCOC program.
Yes
No
5. Is the nominee in campaign status for national, state or federal political office? If yes, nominee is ineligible for
the JCOC program.
Yes
No
6. Has the nominee served in any advisory role to
senior Department of Defense or Military officials,
military installations or the White House?

If you answered YES, please provide name of
advisory council or board, and dates of Service

Yes
No
7. Is the nominee aware of his/her nomination and the program requirements?
submitting nomination.

Please notify nominee before

Yes
No
8. Is the nominee aware of the JCOC dates and agreed to attend the entire conference, if selected?
Yes
No
9. Is the nominee aware that, if selected, it is their responsibility to fund their own transportation and lodging costs
to and from the registration site? Note: DoD funds JCOC from time of registration to end of program.
Yes
No

10. Alternates are placed on a standby list and are notified when positions become available. If not selected for the
primary slot, is the nominee willing to be considered as an alternate?
Yes
No

11. Has the nominee been
nominated for previous
JCOCs?

12. Has the nominee been
selected to attend previous
JCOCs, but was unable to
attend?

13. Has the nominee attended a
previous JCOC? If yes, nominee is
ineligible for future JCOC programs.

Yes

Yes

Yes

No

No

No

14. Has the nominee participated in the following? (Select all that apply)
Service Civic Leader or Educator
Program

Military Orientation Flight

Tandem Jumps with a Military Service
Performance or Special Operations
Unit

Membership any any Defense
Advisory Boards or Panels

Served as civilian ambassador for
Army programs.

Served as civilian ambassador for
Marine Corps

Participated in other installation or
Service outreach programs. If yes,
please indicate...
Indicate here

15. How may DoD benefit from the nominee's participation? Please note, selection panel will give tremendous weight to
this answer.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 113, Secretary of Defense; DoD Directive 5122.05, Assistant Secretary of Defense for Public Affairs (ASD/PA); DoD
Directive 5410.18, Public Affairs Community Relations Policy; and DoD Instruction 5410.19, Public Affairs Community Relations Policy
Implementation.
PRINCIPAL PURPOSE(S): To administer the Joint Civilian Orientation Conference (JCOC) Program; to verify the eligibility of nominators and
candidates and to select those nominated individuals for participation in JCOC.
ROUTINE USE(S): Applicable Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries, Disclosure to the Department of Justice for
Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, and Data Breach Remediation
Purposes Routine Use. The DoD Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of
records notices may apply to this system. The complete list of DoD Routine Uses can be found online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.
The applicable system of records notice is DPA 03, Joint Civilian Orientation Conference (JCOC) Program and can be found online at: http://
dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570580/dpa-dcra-01/
DISCLOSURE: Voluntary; however, failure to provide the required information may delay or result in not being accepted into the JCOC Program.