ARTAS - May 24 - 25, 2012 - El Paso, TX
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This registration form includes participant information to register for the ARTAS training delivered on May 24 - 25, 2012 in El Paso, Texas.

1. Today's date:

	MM		DD		YYYY
Date	Today's date: Date Month	/	Day	/	Year

2. Name (as you want it to appear on your name tag):

Name (as you want it to appear on your name tag): First Name:
Middle Initial (optional):
Last Name:

3. Title (check all that apply):

Title (check all that apply): Medical Director Clinic Coordinator Clinic Nurse	Case Manager Counselor
Other (please specify)

4. Contact information:

Contact information: Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Phone Number:

5. Please enter your email address here:

Please enter your email address here:

ARTAS - May 24 - 25, 2012 - El Paso, TXExit this survey