Registration for: Cultural Competence Conference Tuesday, October 20, 2009
First Name
Last Name
Agency/affiliation
Address
City
State
Zip
Phone
Email	(required for email confirmation)
Payment type	Credit Card Check Purchase Order Agency Transfer (Reference code BMHS-TC-9)
Attendance verification		Continuing Education Units (CEU) For social workers, psychologists, therapists/counselors, pharmacists, occupational and activity therapists
		Certificate of Attendance (COA) For nurses and all other disciplines
PO Number	(purchase orders only)
Hearing interpreter	(Check if required)
Special Accommodations	(Check if required)
Please describe any special accommodations required.