+-----------------+------------------+--------------+-----------------+
| **TITLE OF      | #                |              |                 |
| PROGRAM:**      | ##### Time is Li |              |                 |
|                 | fe: Management o |              |                 |
|                 | f Acute Coronary |              |                 |
|                 |  Syndromes in VA |              |                 |
+-----------------+------------------+--------------+-----------------+
| **LOCATION OF   | **Alexandria,    |              |                 |
| PROGRAM:**      | VA**             |              |                 |
+-----------------+------------------+--------------+-----------------+
| **PROGRAM       | **February       | **PROGRAM    | ########        |
| DATE(S):**      | 25-27, 2004**    | NUMBER:**    | 04.ST.CAR.CON.A |
+-----------------+------------------+--------------+-----------------+
| **CONTACT       | #######          |              |                 |
| PERSON:**       | # Name: Marty Oe |              |                 |
|                 | xner Phone: 314- |              |                 |
|                 | 894-6648 x6247 F |              |                 |
|                 | ax: 314-894-6506 |              |                 |
+-----------------+------------------+--------------+-----------------+

+-----------------+----------------------------------------------------+
|                 | ######## Email: Martin.Oexner@lrn.va.gov           |
+-----------------+----------------------------------------------------+

+-------------------------------------------------+--------------------+
| **REGISTRATION INSTRUCTIONS**                   | #######            |
|                                                 |                    |
| 1.  Download a copy of this form to your        | **REGISTRATION     |
|     personal computer (under FILE, click on     | DEADLINE:**        |
|     SAVE AS, specify SAVE IN destination on     |                    |
|     your personal computer, click SAVE).        | ######             |
|                                                 | # February 9, 2004 |
| 2.  Follow your local approval procedures       |                    |
|     before registering for this program.        | Employee Education |
|                                                 | Resource Center    |
| 3.  Participants from TEMPO II sites must also  |                    |
|     provide this information to EES to complete | #1 Jefferson       |
|     course registration.                        | Barracks Drive     |
|                                                 |                    |
| 4.  Email or Fax completed registration form to | Building 2         |
|     the EES contact person listed above.        |                    |
|                                                 | St. Louis, MO      |
| 5.  If travel is required to attend this        | 63125              |
|     program, funds must be provided by your     |                    |
|     facility/VISN.                              |                    |
|                                                 |                    |
|     -   Your travel clerk will need to prepare  |                    |
|         your travel authority (SF-3036).        |                    |
|                                                 |                    |
|     -   Obtain your travel authority (SF-3036)  |                    |
|         and advance of funds.                   |                    |
|                                                 |                    |
|     -   Obtain a traveler's itinerary worksheet |                    |
|         from your travel clerk.                 |                    |
+-------------------------------------------------+--------------------+

**Participant Information** *(Please type or print clearly)*

<table>
<colgroup>
<col style="width: 9%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>Name:</strong></td>
<td colspan="9"><em>First</em> <strong>     </strong></td>
<td colspan="3"><em>MI</em> <strong>   </strong></td>
<td colspan="13"><em>Last</em> <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
<tr class="odd">
<td><strong>SSN*:</strong></td>
<td colspan="3"><strong>   </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="3"><strong>    </strong></td>
<td colspan="5"></td>
<td colspan="2"><strong>Sex:</strong></td>
<td></td>
<td colspan="5">Male</td>
<td></td>
<td colspan="2">Female</td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Job Title:</strong></td>
<td colspan="24"><em>(40 spaces max)</em><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
<tr class="odd">
<td colspan="14"><strong>Professional Degree(s):</strong> <em>As it
should appear on your certificate</em></td>
<td colspan="12"><em>(15 spaces max)</em> <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
<tr class="odd">
<td colspan="26"><strong>Occupational Category:</strong> Administrative
Associated Health Physician Dentist Nurse</td>
</tr>
<tr class="even">
<td colspan="26"><strong>Employer Category:</strong> VHA VBA NCA Other
Federal Non-Federal</td>
</tr>
<tr class="odd">
<td colspan="26"></td>
</tr>
<tr class="even">
<td colspan="26"><strong>Accreditation/Contact Hours Requested:</strong>
<em>See program brochure for description of Continuing Education Hours
and type of credit offered - <strong>You must attend 100% of the program
and complete the evaluation to receive credit for your
attendance.</strong></em></td>
</tr>
<tr class="odd">
<td colspan="26"></td>
</tr>
<tr class="even">
<td colspan="3">Contact Hours</td>
<td colspan="3"><blockquote>
<p>ACCME</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p>ANCC</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>APA</p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="26"></td>
</tr>
<tr class="even">
<td colspan="8"><p><strong>Social Work License #:</strong> <em>(if
applicable)</em></p>
<p><strong>CA Psychology License#:</strong> <em>(if
applicable)</em></p></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="14">ASWB CA SWCE</td>
</tr>
<tr class="odd">
<td colspan="26"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>Facility/Org Name:</strong></td>
<td colspan="17"><strong>     </strong></td>
<td colspan="4"><strong>Facility #      </strong></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Mailing Address:</strong></td>
<td colspan="17"><strong>     </strong></td>
<td colspan="4"><strong>VISN #</strong> <strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>City / State / Zip:</strong></td>
<td colspan="21"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Service / Dept:</strong></td>
<td colspan="14"><strong>     </strong></td>
<td colspan="7"><strong>Mail Routing Symbol:</strong>
<strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5"><strong>Phone:</strong></td>
<td colspan="14"><strong>     </strong></td>
<td colspan="7"><strong>Fax:</strong> <strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>E-mail Address:</strong></td>
<td colspan="14"><strong>     </strong></td>
<td colspan="7"><strong>Pager:      </strong></td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
</tbody>
</table>

# ALTERNATE NAME BADGE: (*If the name and/or organization should be different on name badge, please indicate below)* 

  ------------------- ----------- -------------- --------- -----------------------------------
  **Name:**           *First*                    *MI*      *Last* **     **
                      **     **                  **   **   

  **Organization:**               **     **                
  ------------------- ----------- -------------- --------- -----------------------------------

*[**While at program, name & number to call in event of an emergency:**
(Required)]{.underline}*

  ----------------------------------- ------------------- ----------------
  *Name:* **     **                   *Day #:* **     **  *Eve #:*
                                                          **     **

  ----------------------------------- ------------------- ----------------

**Please describe any special arrangements due to physical limitation(s)
and/or special dietary requirements**:

  -----------------------------------------------------------------------
  **     **

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  **COMPLETE THIS SECTION IF SUPERVISOR APPROVAL IS REQUIRED FOR
  REGISTRATION**

  -----------------------------------------------------------------------

  --------------------------------- --- ----------------------------------
                                        I certify that the funding is
                                        available to send the participant
                                        to the course, and that the
                                        participant has the time available
                                        to attend the course.

                                        

  Participant Signature                 Supervisor Signature

                                             

  Date                                  Date
  --------------------------------- --- ----------------------------------