Winter 2014 TAC Meeting and Tribal Consultation Session Registration Form

To register to attend the Winter 2014 TAC Meeting and/or 10th Biannual Tribal Consultation Session on February 18-19, 2014, please complete all sections below and click “Register” to submit. Registrations will be accepted until January 29, 2014. If you have any questions, please contact TribalSupport@cdc.gov.

Note: All attendees, including CDC/ATSDR employees and other federal employees, must pre-register using the form below by January 29, 2014. Non-federal attendees who fail to pre-register will be denied access to the CDC campus.

Register

Please fill out all of the fields below. If you have questions, please contact tribalsupport@cdc.gov.

Contact Information
First Name:
Last Name:
Credentials:	i.e. MD, JD, MPH, USPHS Rank, etc.
Tribal Affiliation:	Please list enrolled membership first.
Address:
Phone Number:	Ex: (444) 444-4444
Fax Number:	Ex: (444) 444-4444
Email Address:	For validation purposes. A confirmation email and meeting information will be sent to this address.

I am an elected Tribal Leader or official designee authorized by my tribe to engage in Government-to-Government Consultation

Professional Affiliation
Official Position/Title:
Tribe/Organization/Agency:
Division/Branch/Office (if applicable):
Mailstop (if applicable):

I Plan To Attend*:
	CDC/ATSDR Tribal Advisory Committee Meeting (February 18, 2014)
	10th Biannual CDC/ATSDR Tribal Consultation Session (February 19, 2014)

Syndicated Content Details:
Source URL: http://www.cdc.gov/tribal/registration/index.html
Source Agency: Centers for Disease Control and Prevention (CDC)
Captured Date: 2016-05-23 22:34:23.0

Winter 2014 TAC Meeting and Tribal Consultation Session Registration Form

Register

Contact Information

Professional Affiliation

I Plan To Attend*: