## ![](media/image1.png){width="1.2201388888888889in" height="1.2201388888888889in"} 

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 1%" />
<col style="width: 14%" />
<col style="width: 13%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Full Name:</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="5">Last</td>
<td colspan="4">First</td>
<td colspan="2">M.I.</td>
</tr>
<tr class="odd">
<td colspan="11">Name for workshop badge: <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="11">Rank, Title, or Position: <strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="11">MUST be U.S. citizen and DoD employee or current DoD
contractor</td>
</tr>
<tr class="even">
<td colspan="11"><p>DoD Facility Security Officer (FSO) must submit
signed letter verifying U.S. Citizenship and DoD employee or DoD
contractor status to Workshop Clearance Coordinator (WCC) <u>BY
9/8/08</u> :</p>
<p>Jeanette Laslo, Phone: (505) 284-5668, Fax: (505) 845-3651, email:
jlaslo@sandia.gov</p></td>
</tr>
<tr class="odd">
<td colspan="11">Please provide the following information (*required for
badging process):</td>
</tr>
<tr class="even">
<td colspan="11">*Social Security Number :      </td>
</tr>
<tr class="odd">
<td colspan="4">*Birth Date:      </td>
<td colspan="7">*Place of Birth:      </td>
</tr>
<tr class="even">
<td colspan="6">Business/Organization: <strong>     </strong></td>
<td colspan="5">Telephone: <strong>(   )         </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><p>Mailing/street address:</p>
<p>     </p></td>
<td colspan="4"><p>City/State:</p>
<p>     </p></td>
<td colspan="4"><p>Zip Code:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="3">Mobile Phone : <strong>(   )         </strong></td>
<td colspan="4">Fax: <strong>(   )         </strong></td>
<td colspan="4">email:<strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Administrative Contact:       Telephone: (   )
         email:      </strong></td>
</tr>
<tr class="even">
<td colspan="11"><h3 id="section-1"></h3></td>
</tr>
<tr class="odd">
<td colspan="11"><h3 id="section-2"></h3></td>
</tr>
<tr class="even">
<td colspan="2">Workshop Fee</td>
<td colspan="6">Day 1, 9/23/08: Continental Breakfast, Lunch and
refreshments</td>
<td colspan="2"></td>
<td>$30.00</td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="2">Workshop Fee</td>
<td colspan="6">Day 2, 9/24/08: Continental Breakfast, Lunch and
refreshments</td>
<td colspan="2"></td>
<td>$30.00</td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="2">Social Mixer</td>
<td colspan="6">9/22/08, 6pm, @ MCM Elegante Hotel: Opportunity to
network and receive workshop materials prior to meeting; mixer includes
heavy hor’deurves and no-host bar</td>
<td colspan="2"><p>$16.50 / person</p>
<p># attendees <strong>  </strong></p></td>
<td>$      </td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="2">Workshop Dinner</td>
<td colspan="6"><p>9/23/08, 7pm @ MCM Elegante Hotel; no-host bar; and
indicate:</p>
<p>Petite Filet w/béarnaise and Tiger Shrimp # <strong>  </strong></p>
<p>Salmon w/orange brandy sauce and Tiger Shrimp #
<strong>  </strong></p></td>
<td colspan="2"><p>$40.00 / person</p>
<p># attendees <strong>  </strong></p></td>
<td>$      </td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">TOTAL paid on Webpay via Website:</td>
<td colspan="3">$     </td>
</tr>
<tr class="even">
<td colspan="11"><em>Please indicate any special dietary requests:</em>
     </td>
</tr>
<tr class="odd">
<td colspan="11"><h3 id="section-3"></h3></td>
</tr>
</tbody>
</table>