OTI 5600 - Disaster Site Worker Train the Trainer Course

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
Are You Vegetarian?
List Any Food Allergies
Notes/Comments
Registration Dates, Locations and Fees
Please check which course you are registering for.

Course Registration: $750.00
 
Location
Start Date
End Date
2008
Tampa, FL
September 02
September 05
Miami, FL
November 10
November 13
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.