Registration HIV Series 9.13.12 Survey

Thank you for registering for the HIV SERIES for HEALTH CARE PROVIDERS to be held on Thursday, September 13, from 12 - 1 pm at LSU Health Clinic, 2235 Poydras Street, Conference Room 158, New Orleans.

*
1. Please provide the following information:

Please provide the following information: First Name:
Last Name:
Agency:
Address:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

2. Would you like to propose a question for the presenter to answer on the day of the program? If so, please indicate below:

Would you like to propose a question for the presenter to answer on the day of the program? If so, please indicate below:

Registration HIV Series 9.13.12

1.

*1. Please provide the following information:

2. Would you like to propose a question for the presenter to answer on the day of the program? If so, please indicate below:

*
1. Please provide the following information: