Elected Officials Workshop Registration Form

North Carolina Department of Public Safety

Emergency Management

Beverly Eaves Perdue, Governor Reuben F. Young, Secretary H. Douglas Hoell, Jr., Director

INCIDENT COMMAND SYSTEMS (ICS) OVERVIEW FOR EXECUTIVES AND SENIOR OFFICIALS STATE OF EMERGENCY LEGAL ISSUES

Date: March 14, 2012 Location: Sea Trail Conference Center, Sunset Beach, NC

Please fax or email this registration form to the attention of Dianne Benton at 919- 825-2684 or [email protected].

Name (please print clearly): Last First M.I.

Business Address:

Daytime Phone: ______

Email Address: ______

County/City: ___ Position / title:

Please check the sessions you will be attending. Also, please check if you will be present for lunch:

_____Incident Command Overview for Executives and Senior Officials

_____State of Emergency Legal Issues

_____Lunch

MAILING ADDRESS: OFFICE LOCATION: 4713 Mail Service Center 1636 Gold Star Drive Raleigh NC 27699-4713 Raleigh, NC 27607-3371 Telephone: (919) 825-2500 www.ncem.org Fax: (919) 825-2685 An Equal Opportunity/Affirmative Action Employer 2EM FORUM

Do you have a disability that would require special consideration during your course attendance? If so, please explain what we can do to accommodate your needs:

______

MAILING ADDRESS: OFFICE LOCATION: 4713 Mail Service Center 1636 Gold Star Drive Raleigh NC 27699-4713 Raleigh, NC 27607-3371 Telephone: (919) 825-2500 www.ncem.org Fax: (919) 825-2685 An Equal Opportunity/Affirmative Action Employer