Registration Information: Registration Fee – $15.00 per person Registration forms may be mailed, emailed or faxed. Checks should be made payable to VDH-TUCP. Payments must be mailed by Monday, October 26, 2009, to confirm your attendance.

Mail: Attention: B.A. Caro-Justin            
VDH –TUCP
109 Governor St. – 10th Fl
Richmond, Virginia, 23219
Fax:                  (804) 864-7880
Questions:        (804) 864-7876
Email                ba.caro-justin@vdh.virginia.gov

First Name:

Last Name:

Organization/Agency :

Subject:

Address:

City:

State:VA
Zip Code:

Phone:

(804)555-5555

Your Email Address:

Check enclosed (w/mailed registration form)

Emailed registrations – reference attendee’s name to: ba.caro-justin@vdh.virginia.gov

Faxed registrations ~ reference attendee’s name send to: TUCP – 804-864-7880

Check to be mailed to: B.A. Caro-Justin, VDH – TUCP, 109 Governor St. 10th Fl, Richmond, VA 23219

Please choose Yes if you would like a vegetarian option for lunch

Yes No

Please check if you will need additional assistance – i.e. interpreters, accommodations, etc.

Please clarify the need

Hotel Accomodations:
Please contact the Marriott Richmond West Hotel at 1-888-839-0610 to reserve a hotel room. Please identify yourself as attending the Tobacco Use Control Project Annual Training Meeting. The conference rate for the hotel room is $93.00 and is subject to applicable state and local taxes (currently 13% per room per night). Rates are available November 4 through November 6, 2009. The Deadline for Hotel Reservations for this event is October 26, 2009. For Additional Information check our website::www.vahealth.org/cdpc/tucp

Application to Exhibit
TUCP Annual Training Meeting – November 5, 2009

WE’RE COMING! SIGN US UP AS AN EXHIBITOR! Yes No

Exhibit Fee $35.00:

Payment