USGS

Office of Organizational and Employee Development

Application for Non-DOI Employees to attend U.S. Geological Survey Course,
Office of Organizational and Employee Development,
USGS National Training Center
Denver, CO

NOTE: Please print the following form on your printer, complete the form, have your supervisor sign it and date it, and then fax it to Gloria Armstrong, Office of Organizational and Employee Development, at 303-445-4665. Gloria will notify you as soon as possible regarding the status of your application.

Please print legibly.

APPLICANT INFORMATION
First Name:
 ______________________
Last Name:
 ______________________
Full E-Mail Address:

_________________ @ _______________
Job Title/Series:
 ________________________________________
Agency or Office:
 ________________________________________
Office Street Address:

________________________________________________
City:
_______________ State: _____    Zip Code: ____________
Office Phone Number:
 (___) ____________ Ext.: ________
Fax Number:
 (___) ____________
COURSE INFORMATION 
Course Title:

______________________________________________________________

______________________________________________________________
Course Number (e.g., SW2040TC):
 _____________________
Course Begin Date:
 ___________________
Course End Date:
 ___________________
BILLING INFORMATION
Billing Contact's Full Name:
 _______________________________________________
Billing Office Street Address:

________________________________________________
City:
 ___________________ State: _____    Zip Code: ____________
Billing Office Phone Number:
 (___) ____________ Ext: ________
Agency Location Code (OFA Only):
 ________________________________________
Type of Credit Card:
 ________________________________________
Full Name on Credit Card:
 ________________________________________
Card Identification Number :
 ________________________________________
Credit Card Number:
 ________________________________________
Credit Card Expiration:
 Month: ___________ Year: ______________
SUPERVISOR'S APPROVAL
Supervisor's Signature:
 ______________________________________________
Date:
 _______________________

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