• Please provide the following contact information. ALL Info is needed to qualify for HMEP Grant funding.

  First Name
  Last Name
  Title
  Hazmat Team Affiliation
  Fire Department Affiliation
  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code
  County of Residence
  Last 4 Digits of Social Security Number (Needed for HMEP Grant Funding)
  Daytime Phone
  E-mail
  Verify E-mail

  

  

            NOTE: The HAZMAT IQ & CHLORINE CLASSES ARE NOW FULL.

• Have you attended this conference in the past:             Yes No
  
• What is your highest level of Hazmat/WMD Training:  Hazmat Awareness Hazmat/WMD Awareness Hazmat Operations Hazmat/WMD Awareness Hazmat Technician Hazmat/WMD Technician Hazmat Specialist Hazmat/WMD Specialist Bomb Technician Other
• What Public Safety Discipline do you work in:            Fire Service Emergency Medical Services Emergency Management Law Enforcement Bomb Technician Hospital Medical Hazmat Response Only Other
• Pre-Conference, October 31, 2008 -                             No Pre-Conference    Sorry: Both Pre-Conference classes are full.
• Main Conference, November 1, 2008                        I will attend the main conference No Main Conference