Form 7674 - Media Accreditation / Embed Application
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2MEDIA ACCREDITATION/EMBED APPLICATION
For use of this form, see STP 46-46QZ14-SM-TG; the proponent agency is TRADOC.
PRIVACY ACT STATEMENT
Chapter 5, AR 360-1.
AUTHORITY:
For the use of this form see AR 360-1; the proponent agency is the Army Public Affairs Center.
PRINCIPAL PURPOSE:
To obtain information from members of the media desiring to embed or gain accreditation.
ROUTINE USES:
Disclosure of information requested on this form is voluntary. Failure to provide the required information will result in
DISCLOSURE:
non-acceptability of the application.
PERSONAL DATA
1. Name (Last, First, MI):
2. Date of Birth
3. Agency:
(YYYYMMDD):
9. Phone #
4. PIC ID#
5. Exp.Date
6. Passport #
7. Country
8. Exp. Date
10. Alt. Phone #
11. Blood Type
12. Height
13. Weight
14. E-Mail
15. Alt. E-Mail
MEDICAL SCREENING
Are you allergic to any medications? (Check box if Yes
and list)
To your knowledge, do you have any heart condition?
(Check box if Yes and list)
Do you have any disabilities that prohibit you from
running? (Check box if Yes and list)
Are there any other medical conditions that may be of
concern during your embed? (Check box if Yes and list)
EMERGENCY CONTACTS
First Contact:
Second Contact:
1. Name
(Last, First, MI):
1. Name
(Last, First, MI):
2. Address:
2. Address:
3. Phone # :
3. Phone # :
4. Relationship:
4. Relationship:
5. E-Mail:
5. E-Mail:
SUPERVISOR/MANAGER INFORMATION
1. Name
2. Phone # :
(Last, First, MI):
3. Agency (If Different):
4. Address:
5. E-Mail:
EMBED INFORMATION
1. Estimated Arrival Date:
2. Arrival Location:
3. Requested Start Date:
4. Requested End Date:
DA FORM 7674, OCT 2010
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APD LC v1.01ES
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