Registration Form

Thank you for your interest in the Connecticut Drugged Driving Summit. Please complete the registration form below. A member of our staff will send you a confirmation email shortly.

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* 1. First Name:

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* 2. Last Name:

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* 3. Organization:

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* 4. Street Address:

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* 5. City:

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* 6. State:

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* 7. Zip Code:

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* 8. County:

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* 9. Phone Number with Area Code:

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* 10. Email Address:

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* 11. Are you a:

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* 12. Do you need hotel accommodations?

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* 13. Do you need to receive credit for attendance?

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