OF EMERGENCY PREPAREDNESS

1230 Congress Street, Portland, ME 04102

Maine Department of Health and Human Services, Maine CDC

Registration Form

Please fill out the Registration form below completely. Fields marked with an * are required.

Please Do Not Use Acronyms.

Deadline to register is April 9, 2008.

First Name:*   Last Name:*   

(as you wish it to appear on name badge)

Job Title:* 

Organization/Agency:  

Mailing Address:*  

Address 2:  

City:*   State:*   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nevada New Hampshire New Jersey New Mexico Nebraska North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip:*  

Phone:*   (000-000-0000)

Fax:   (000-000-0000)

E-mail:*   

Please check the job description that best matches your PRIMARY position. Check only one box.

For more information please contact: Viki Wills vwills@mcph.org, (207) 629-9272 Ext. 212