Form CDC 36.5 CDC 36.5 Att. 3_New Participant Registration Form

New Participant
Registration
Participant Profile
*

First Name

*

Last Name

Action: Approved
OMB No.: 0920-0017
Exp. Date: 06/30/2006

Middle Initial
*

Address

*

City

*

State

Georgia

*+ Zip Code:
*

Country:

United States

Daytime Telephone:
*

Are you a CDC/ATSDR
employee?

*

Are you in the military?

*

Place of employment

*

E-Mail:

*

Confirm E-Mail:

Yes

Yes

No

No

If so what branch?

Select

Note: You must enter the correct email address to register online.
Click here if you wish to be notified via email of upcoming events or other information.
* = Required Items

+ = For U.S. Only
Public Burden Statement:

The information requested on this form is collected under the authority of 42 U.S.C., Section 243 (CDC) and the Comprehensive
Environmental Response, Compensation, and Liability Act (CERCLA) (42 U.S.C. 9604 (i)) and its 1986 Amendments, The
Superfund Amendments and Reauthorization Act (SARA) (ATSDR). The requested information is used only to process your
training registration and will be disclosed only upon your written request. Continuing education credit can only be provided
when all requested information is submitted.
Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR
Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0017)

Submit
URL: https://www2a.cdc.gov/phtnonline/newmember.asp