Registration – Bus Conversion Training – Ramkota 9:00-4:00
* 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: Bus Conversion Training – Ramkota 9:00-4:00 Course location: Bismarck - Best Western Ramkota Hotel Course starting date: 6/26/2013 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.