JCOC Registration Form

Joint Civilian Orientation Conference (JCOC 92)
Registration Form
November 3-8, 2020

(This Form Must Be Typed)
OMB CONTROL NUMBER: 0704-0562
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,
Office of Information Management, at < [email protected] > for OMB Control No. 0704-0562. 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 FORM

(This registration form is considered confirmation of attendance. Registration is not complete without the "Required Documents" listed below.)
Required Documents:

Please email all items or direct questions to:
Ms. Laura Ochoa, JCOC Program Manager, at
[email protected] or (703) 614-3246
AND
Major Vincent Gothard, at
[email protected] or (703) 695-3381

- Typed Registration Form (emailed by Sep 27, 2020)
- Updated 250 Word Biography (emailed by Sep 27, 2020)
- Digital Hi-Res Headshot Photograph (emailed by Sep 27, 2020)
- Medical Form (May be emailed by Oct 18, 2020)

ATTENDEE INFORMATION
Last Name

First Name

Middle Name

Company

Title

Work Phone:

Work Email

Home Address

Personal Email

Your Preferred Method of Contact
(Select preference for phone and email)
Work Phone
Work Email

Cell Phone
Personal Email

Preferred Name (for badge)

Work Address

Home Phone

Emergency Contact
Name:
Home Phone:
Cell Phone:
Email:
Relationship:

Cell Phone

Dietary Restrictions (List Allergies Only)
(Please remember that meals will be served at the hotels or military dining facilities. We may not be able to accommodate food preferences.)

PRIVACYACT 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.