2 - JCOC Registration Form

JOINT CIVILIAN ORIENTATION CONFERENCE 93
Registration Form
October 23 - 29, 2022

OMB Control Number: 0704-0562

Agency Disclosure Notice

OMB Expiration Date: March 31, 2026

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, VA22350-3100 [0000-0000]. 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.

(This registration is considered confirmation of attendance. Registration is not complete without the “Required Documents” listed below.)
Please email all items or direct questions to:

Required Documents:
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The JCOC Program Office at osd.pentagon.pa.mbx.jcoc-admin@mail.

Typed Registration Form
Updated 250 word biography
Digital hi-res headshot
Medical Form

Attendee Information
Last Name

First Name

Title

Organization

Work Email

Work Phone

Preferred Mailing Address

Personal Email

Your Preferred Method of Contact

Middle Name

Preferred Name (for badge)

Cell Phone

Emergency Contact

(Select preference for phone and email)

☐ Work Phone

☐ Cell Phone

Name

☐ Work Email

☐ Personal Email

Phone
Email
Relationship

Dietary Restrictions (List Allergies Only)
(Most meals will be provided at 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.