Executive Course Defense Industry On-Line Registration Form

Note: This form is designed for defense contractor personnel who wish to attend the DISAM SAM-E Course. This five-day course will be offered three times in each Fiscal Year:

SAM-E-1-12	Nov 14 -Nov 18 2011
SAM-E-2-12	Apr 23 - Apr 27 2012
SAM-E-3-12	Jun 18 - Jun 22 2012

The current tuition cost is approximately $2,021 (subject to change) which covers all textual materials, including the textbook The Management of Security Assistance and an instructional copy of the Security Assistance Management Manual, DoD 5105.38-M. Note: Tuition payment must be paid in advance or no later than class start date.  Preferred method of payment is wire transfer or alternate method of payment by check, made out to Treasurer of United States and mailed to DISAM/DAS-E, 2475 K Street, Area B, Bldg 52, Wright-Patterson AFB OH 45433. Banking information to send wire transfer to DFAS-IN from a US Bank: ABA#021030004, US Treasury NYC, Agency Location Code: 00003801, Beneficiary: DFAS-JAX/IN Agency.  Send a copy of wire transfer and student name/s to DISAM via e-mail to Registrars@disam.dsca.mil.  For further information please contact: SAM-E Course Coordinator, (937) 255-5850.

Privacy Act Statement - As part of the registration information you will be requested to provide your Social Security Number. The purpose is to prevent duplicate student name entries in the data base. Privacy act 1974 as amended applies. This registration may contain information which must be protected IAW DoD 5400.11R. 

PLEASE FILL OUT THE FOLLOWING FORM AND FAX TO REGISTRAR OFFICE:

FAX (937)255-3441, DSN 785-3441

Please provide the following contact information:

Name
Position Title
Company Name
Business Address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Business Phone
FAX
E-mail
USA Citizenship	Yes No
On base Accommodations	Yes No
Desired Class Date	SAM-E-1-12: Nov 14 - Nov 18 2011 SAM-E-2-12: Apr 23 - Apr 27 2012 SAM-E-3-12: Jun 18 - Jun 22 2012   1st Choice None SAM-E-1-12: Nov 14 - Nov 18 2011 SAM-E-2-12: Apr 23 - Apr 27 2012 SAM-E-3-12: Jun 18 - Jun 22 2012   2nd Choice
Billing address
Address (cont.)
City
State/Province
Zip/Postal code
Country