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:  HC Standard Training - 1:00 - 5:00 Afternoon Class
Course location:  Minot - Riverside Education Center - 1900 8th Ave SE
Course starting date:  11/27/2012

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.