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Alaska Native Tribal Health Consortium
Health Information & Technology
4000 Ambassador Drive; 3rd Floor
Anchorage, Alaska 99508

Toll Free (877) 885-5672
Phone (907) 729-2260
Fax (907) 729-2269
Email afhcansales@afhcan.org

© Alaska Native Tribal Health Consortium 2000-2007

   Training Request Form

  Your Name:
  Job Title:
  Your Phone Number:
  Your Email:
  Your Fax Number:
 
Supervisor's Name:
  Supervisor's Phone Number:
  Health Care Organization:
  Site/Location:
 
Training Requested:
(pick one)
 
New User (8 hours)
 
Refresher (4 hours)
 
Orientation (1 hour)
 
Train-the-Trainer Workshop (5 days)
  Dates available for training:
  Number of Trainees:
 
Request training at:
(pick one)
 
AFHCAN Anchorage Training Center
 
Your Regional Medical Facility
 
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