Infection Control Part II: The Infection Control Professional as an Environmentalist

September 8–12, 2008

Payment must accompany registration. Print out and mail or fax to the Friday Center. Please print or type.

Name_____________________________________________________________________________

Hospital/Facility______________________________________________________________________

Hospital/Facility Mailing Address_________________________________________________________

City_________________________________________________State_______Zip________________

Daytime Phone (______)______________________________________________________________

E-mail (please print clearly) ____________________________________________________________

UNC-Chapel Hill uses the Personal ID number (PID) to aid in keeping records. If you already have a PID, please enter it.

PID #______________________________________________________________________________

If you do not already have a UNC PID, please provide the following information required for PID number creation:

Gender: M   F     Birth Date_________________________________________________________

Are you an alumnus of UNC-Chapel Hill? Yes No. If yes, when did you graduate?______________

County in which Hospital/Facility is located_________________________________________________

Occupation/Specialty _________________________________________________________________

In what type of facility do you work?_______________________________________________________

Please indicate the accommodations and/or services you require to participate: ______________________________________________________________________________

Payment must accompany this form. Method of payment:

Check for $475 (in-state) or $525 (out-of-state), payable to the Friday Center (Federal ID#56-6001393).

VISA or MasterCard (Credit card may be received by mail, fax, or phone.)

Mail or fax this form with payment to:
Infection Control Part II 2503
CB 1020, The Friday Center
UNC-Chapel Hill
Chapel Hill, NC 27599-1020
Fax: 919-962-5549.