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Event Title: Application for STD/HIV/TB Clinical Update
Date: 19-Apr-18

We collect the following information solely for the purpose of facilitating the on-line registration process for our events. This information is not stored with or connected to your unique PIF ID.
Email:    * required
Confirm Email:    * required
Save Info:    (Save your contact information to ease future registrations.)
First Name:    * required
Last Name:    * required
Title:    * required
Organization:  * required
Address:  * required
City:  * required
State:  * required
Zip Code:  * required format(xxxxx-xxxx)
Phone:  * required format(xxx-xxx-xxxx)
Phone 2:   format(xxx-xxx-xxxx)
 Physician Assistant
 Nurse Midwife
 Social Worker
 Case Manager
 Mental Health Provider
 Substance Abuse Professional
 Health/HIV Educator
 Grants Manager
 Project Manager
 Non Health Discipline

 Other Dental Professional
 Nurse Practitioner
 Advanced Practice Nurse
Do you want to receive CME/CEUs?     Yes     No

If you are receiving CME/CEUs, what type of CME/CEUs would you like to receive ?   
 Nursing     Medical    *License Number 
Which meal do you prefer?    Regular     Vegetarian      Vegan     None. I will not be eating onsite.