Safety Week

Safety Week Registration Form (Items in Red are required fields)

First Name
Last Name
Degrees
Prof. Title
Gender	Male Female
E-mail
Home Phone
Work Phone
Fax

Company
Department
Address
Address2
City
State
Zip
Country

ADA Describe Any Disabilities
Notes/Comments

Registration Dates, Locations and Fees

Please check which Safety Week you would like to register for.

Location/Courses included in Safety Week		Start Date	End Date
Introduction to OSHA Safety Week
	Mobile, AL	July 28, 2008	August 1, 2008
	Tallahassee, FL	October 6, 2008	October 10, 2008
Construction Safety Week #1
	Orlando, FL	June 2, 1008	June 6, 2008
HealthCare Safety Week
cancelled	Clearwater, FL	March 24, 2008	March 28, 2008
Construction Safety Week #2
	Miami, FL	October 6, 2008	October 10, 2008
Disaster Safety Days
	Orlando, FL - cancelled	April 21, 2008	April 24, 2008

Payment Method
(Note: You will not be charged until registration is confirmed.)

Cancellation Policy
Cancellation notification must be in writing (FAX or email are acceptable). A cancellation fee equal to 25% will be assessed. Written cancellations received less than 5 working days prior to the event will be charged the cancellation fee plus the per-person cost. No-shows will be billed. Substitutes are welcome without penalty.

The Continuing Professional Education Office at the University of South Florida Health Sciences Center reserves the right to cancel this activity due to unforeseen circumstances. In the event of such cancellation, only the registration fee will be returned to the registrant.

Credit Card

	Mastercard
	Visa
	American Express

Name (exactly as on card)
Credit Card Number
Expiration Date (mm/yy)
CVC Code

Check

Please make checks payable to:

USF HPCC
PO Box 864240
Orlando, FL 32886-4240

On your check, please include the program code which is printed on your confirmation and the registrants name or a copy of the registration.

Bill Later For Registrations Paid By PO

PO Number


If billing address is different than above - please list below
Company
Attn:
Address
City	State	Zip
Phone EMAIL

Security Notice

Accommodations for Disabilities: Please notify the CME Office, 12901 Bruce B. Downs Blvd., MDC Box 60, Tampa, Florida, 33612 or call (813) 974-6695 a minimum of ten working days in advance of the event if a reasonable accommodation for a disability is needed.

Events, activities and facilities of the University of South Florida are available without regard to race, color, sex, national origin, disability, age, or Vietnam veteran status as provided by law and in accordance with the University's respect for personal dignity.