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Connecticut Drugged Driving Summit
Registration Form
Thank you for your interest in the Connecticut Drugged Driving Summit. Please complete the registration form below. A member of our staff will send you a confirmation email shortly.
1.
First Name:
2.
Last Name:
3.
Organization:
4.
Street Address:
5.
City:
6.
State:
7.
Zip Code:
8.
County:
9.
Phone Number with Area Code:
10.
Email Address:
11.
Are you a:
Attendee
Sponsor
Speaker
12.
Do you need hotel accommodations?
Yes
No
13.
Do you need to receive credit for attendance?
Yes
No