CALIFORNIA EH&S ACADEMY 2008 ONLINE REGISTRATION

	*REQUIRED FIELD
	*First Name:
	Middle Initial:
	*Last Name:
	*Work Phone Number:
	*Alternate Number:
	Certification:
	*E-mail Address:
	*Location:
	*Work Address:
	Address Line 2:
	*City:
	*State:
	*Zip Code:
	(UC only) FAU (account number):
	(UC only) FAU Contact:
	(UC only) FAU Contact Phone:
	Non UC registrants make check payable to UC REGENTS and submit to: Sharon Culpepper UC Office of the President, EH&S 1111 Franklin Street, 10th Floor Oakland, CA 94607-5200
	Please specify below any special accommodations and/or dietary needs. (If this does not apply to you, please leave blank)