Registration – ICS Functional Exercise
* Required fields
Name: *First name: Required Middle initial: *Last name: Required
Contact Information: *Day: Required Evening: Fax #: *Email address: Required Invalid email address
Your Organizations Information: *You are representing: Required *Current position: Required *Category: PhysicianNursePublic HealthOther MedicalDoH EmployeeOther Required
Mailing Address: *Work: Required *City: Required *State: Required *Zip Code: Required
*I will be attending:In PersonVideo ConferenceTeleconferenceWebcast Required If attending via video conference please specify conference room location:
Course Information: Name of course: ICS Functional Exercise Course location: Bismarck - 1:30 to 4:30 Course starting date: 7/31/2014 Remember me Checking this box will store the personal information you entered above in a cookie on your computer. The next time you visit this form your information will automatically be filled in by your computer.