SATNET REGISTRATION FORM
(It is important to complete all information requested below.)

Name - include degrees and/or certifications (Example: Doe, RN, MS, MBA)


Last Name Last Degrees First Name Middle Initial



Position: bullet CEP, EMT, Firefighter      bullet RN      bullet MD      bullet RT      bullet Other ___________________   (please specify)


Title (Example: Nurse Manager, Director, Captain, etc.)


Organization


Organization Address


City State Zip Code


Home Address (not for publication)


City State Zip Code

(            )                                        (            )
Area Code / Home Phone               Area Code / Work Phone             E-mail:   Home   /   Work   ( please circle )


For More Information, Please Contact:
Clint Brown
Phone: 520-795-2170
Fax: 520-626-5016
e-mail: clbsatnet@aol.com

Please indicate T-shirt Size: 		There is a $12.00 membership fee to join.
Please make the check out to SATNET
and return with registration form to:
Clint Brown
SATNET
PO Box 43818
Tucson, Arizona 85733-3818