Conference Registration

OMB CONTROL NUMBER: XXXX-XXXX
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services
Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 [Insert OMB
Control Number]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any
penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

CONFERENCE REGISTRATION

Conference Dates:
This registration form is considered confirmation of
attendance.
Please submit all items to:
Items to email by
- Registration Form
- Brief Biography (300 words or less)
- Digital Photograph (Headshot)
- Medical Form

ATTENDEE INFORMATION

Full Name (Last, First, MI):

Preferred Name on name tag:

Title:

Company:

Work Address:

City & State:

Zip Code:

Email:

Phone:

Cell Phone:

Home Address:

City & State:

Zip Code:

Email:

Phone:

Preferred Method Of Contact:
Work
Home

Emergency
Contact:

Email:

Phone:

Alternate Phone:

List Special Needs and Dietary Restrictions:

Please direct all questions to:
JCOC Program Manager
Phone:
E-mail:

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.