2016 Beyond Benign Professional Development Registration * 1. Contact Information Name: School: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: * 2. Indicate which course you are registering for Intro Green Chemistry Online Course (6/13/16-8/8/16) Advanced Green Chemistry Online Course (6/20/16-7/31/16) In-person Green Chemistry Institute (6/28-6/29/16) * 3. At what email address would you like to be contacted? * 4. What classes do you teach? General Chemistry AP Chemistry Earth Science Biology Environmental Science Other (please specify) * 5. How did you hear about this course? (check all/any that apply) Beyond Benign Newsletter Beyond Benign Website Co-worker Conference Social media Other (please specify) * 6. Reason for participating in the course Done