Enclosure (3) to COMDINST 1750.4D
PAGE 2 OF CG-6078 (3-06)
PREVIOUS OMBUDSMAN/RELATED EXPERIENCE
8. HAVE YOU EVER BEEN A COMMAND FAMILY OMBUDSMAN BEFORE?
YES
NO
IF YES, LIST BELOW:
COMMAND:
DATES:
REASON FOR LEAVING:
9. HAVE YOU PREVIOUSLY COMPLETED OMBUDSMAN BASIC TRAINING?
YES
NO
DATE COMPLETED:
LOCATION OF TRAINING:
10. OTHER TRAINING/EXPERIENCE THAT WILL HELP YOU PERFORM THE DUTIES OF AN OMBUDSMAN:
MEDICAL HISTORY
11. DO YOU HAVE ANY MEDICAL PROBLEMS THAT MIGHT RESTRICT YOU FROM PERFORMING NECESSARY
DUTIES (DEPENDING ON THE COMMAND, CAN REQUIRE GOING ABOARD A SHIP OR BOAT TO GIVE A
BRIEFING):
YES
NO IF YES, PLEASE EXPLAIN:
REFERENCES
(PLEASE READ CAREFULLY)
12. LIST THREE REFERENCES. INCLUDE NAME, COMPLETE ADDRESS AND PHONE NUMBER OF EACH. MEMBERS
OF YOUR FAMILY AND INDIVIDUALS WHO RESIDE IN THE SAME HOUSEHOLD MAY NOT BE USED AS
REFERENCES. PLEASE ADVISE YOUR REFERENCES THAT THEY MAY BE CONTACTED BY THIS COMMAND.
REFERENCES MAY INCLUDE MEMBERS OF THIS OR FORMER COMMANDS AS WELL AS EMPLOYER, FORMER
EMPLOYER, ETC.
A. Name:
Phone #:
Address:
B. Name:
Phone #:
Address:
C. Name:
Phone #:
Address:
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