Name:
*First name:    Middle initial:    *Last name:  

Contact Information:
*Day:     *Evening:     Fax #:   
*Email address:   

Your Organizations Information:
*You are representing:   
*Current position:   
*Category:  PhysicianNursePublic HealthOther MedicalDoH EmployeeOther

Mailing Address:
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*City:      *State:     *Zip Code:  

*I will be attending:In PersonVideo ConferenceTeleconferenceWebcast
If attending via video conference please specify conference room location:

Course Information:
Name of course:  HC Standard Training - 1:00 - 5:00 MT Afternoon Class
Course location:  Dickinson - City Police Dept - Law Enforcement Training Room (basement) - 66 West Museum Dr.
Course starting date:  1/29/2013

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