2012 CPS Update Registration Complete this form to register for the 2012 CPS Technician Update. You MUST enter an email address to register with this form. (If you do not receive a confirmation of your registration within 5 working days, please resubmit) Registration Deadline March 7, 2012 for Nebraska CPS Technicians requesting lodging March 15, 2012 for all other CPS Technicians
Your Name *
Your Organization
Mailing address
City *
State *
Zip
Home phone
Work phone
Fax number
Email (REQUIRED) *
Safe Kids Technician Number *
Check all appopriate lines:	Tue. 3/20, I will be attending breakout sessions from 1:00 to 3:00   Tue 3/20, I will be attending the Check Up Event from 4:00 p.m. – 7:00 p.m. and need seat check opportunties for recertification   Tue 3/20, I will be attending the Check Up Event from 4:00 p.m. to 7:00 p.m. but do NOT need seats checked   Wed 3/21, I will be attending the Nebraska CPS Technical Update from 8:15 a.m. – 5:00 p.m.
Lodging needs for March 20: (*To determine mileage use www.mapquest.com “Directions”.)	I am traveling 100 miles or more and request lodging (double occupancy).   No lodging requested
Roommate request?
I prefer a private room and will pay for my own lodging	I will make my own arrangements with Holiday Inn (308-237-5971).
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