NIOSH 2013 Pesticide Handler Personal Protective Technology Stakeholders Meeting Registration*

Name

Are you a citizen of the United States? Yes   No

For non-U.S. citizens (if applicable) — Federal clearance requirements for non-U.S. citizens to enter a federal facility requires a minimum 30 days to process. Therefore you must register by February 23, 2013.

You must present a photo ID in order to enter the federal facility in Washington, DC. Government employees may use their federal ID, otherwise please be prepared to present your Drivers License, or other government-issued photo ID, such as a passport.

You must complete the NIOSH Security Information Requirements for International Visitors Form and submit it to NPPTL Event Management along with a copy of your passport. NIOSH approval must be granted before admittance to the NIOSH site will be allowed. All meeting attendees must show a valid photo I.D. (preferably a driver’s license), and all foreign national citizens must show a current passport, before admittance to the site will be permitted.

Organization/Company

Job Title

Category (select one category that best describes your job. If not employed, select the one that best describes your interests)

Pesticide Handlers (applicators, mixers/loaders, etc.)
Supervisor/Employer of pesticide handler(s)
Educator/Trainer
PPE Supplier
Pesticide Supplier
PPE Manufacturer
Pesticide Manufacturer
Researcher (health or safety)
Regulator/Enforcement
Other (specify)  
N/A

Mailing Address

City

State/Province

Country

Postal Code

Office Phone

Cell Phone

Email Address

Fax

Do you want your contact information included in a list of attendees to be distributed in the program materials?
 Yes  No

A confirmation email will be sent to the email address provided above. If this email is not received within 24 hours of submitting your registration form, please contact NIOSH NPPTL at 412-386-6111 or NPPTLEventsPesticide@cdc.gov.

I agree to the following two items:   Yes  No

1. By registering at this site, I agree to participate in-person in Washington DC. If you intend to participate remotely via Live Meetings, go to: https://www.livemeeting.com/lrs/1100003614/Registration.aspx?pageName=lx5wbfv03vl92kzj
2. For non-U.S. citizens (if applicable) — Federal clearance requirements for non-U.S. citizens to enter a federal facility requires a minimum 30 days to process. Therefore you must register by February 23, 2013.