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FORM "A"

THE OFFICIAL STATE CONTACT FOR MY STATE
Course: Communications Skills for Regulators

 

 

I HAVE NETWORKED WITH MY STATE COUNTERPARTS & AGENCIES AND AGREE TO BE:

Official State Contact:____________________________________Title:_______________________________

Agency:____________________________________________________________________________

Phone ( ) _____ - _______ Fax ( ) _____ - _______ E-mail ___________________________________

Agency Mail Address: Agency Fed Ex Address: (if same as mail, check here ? )

_______________________________________ _____________________________________________

_______________________________________ _____________________________________________

_______________________________________ _____________________________________________

State________ Zip Code___________________ State_________ Zip Code______________________

 

NOTE: If the individual overseeing registration for the state is not the same person performing the role of the Official State Contact, then please provide the following information:

REGISTRAR: Those individuals wishing to register in your state for the course should contact:

Registrar’s Name:_____________________________

Phone ( )_____ - _______ Fax ( )_____ - _______ E-mail:________________________________

Anticipated Participation:

number of participants _______

number of downlink sites _______