• 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

  

  

• 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 Industrial Responder Other
• Pre-Conference, November 6, 2009                          No Pre-Conference   
• Main Conference, November 7, 2009                        I will attend the main conference No Main Conference

          By completing and submitting this registration I agree to receive emails regarding this and future conferences. This info will not be used for any other purpose.