Registration

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33% of survey complete.

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* 1. Site number (if known)

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* 2. Site:

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* 3. Address

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* 4. Toxicology service Director (if applicable)

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* 5. Contact Details:

Name:

Address:

Email:

Telephone:

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* 6. Qualifications and Toxicology Background (Years experience/training)

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* 7. Nominated Day and Time to videoconference each month:

	Day	Week of month	Time (24 hrs -00)( to nearest hour)	Timezone (Universal Time)
Preference 1:	Preference 1: Day menu	Preference 1: Week of month menu	Preference 1: Time (24 hrs -00)( to nearest hour) menu	Preference 1: Timezone (Universal Time) menu
Preference 2:	Preference 2: Day menu	Preference 2: Week of month menu	Preference 2: Time (24 hrs -00)( to nearest hour) menu	Preference 2: Timezone (Universal Time) menu
Preference 3:	Preference 3: Day menu	Preference 3: Week of month menu	Preference 3: Time (24 hrs -00)( to nearest hour) menu	Preference 3: Timezone (Universal Time) menu

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* 8. Other specified time to conference (optional):

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* 9. Looking to videoconference with another toxicology centre

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* 10. Looking to conference with a centre without toxicology service:

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* 11. Any prearrangements with another centre to conference, please list and include times/day:

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* 12. I have read, understood and accepted the disclaimer/conditions (listed on the registration page) and any other member of my institute who plans to partake in the "Global Educational Toxicology Project (GETUP)" will do the same prior to participation.

I agree, understand and accept these conditions/disclaimer. Any other institute members have given implied consent by participating that they understand the conditions stated above.