NEBRASKA DEPARTMENT OF
ENVIRONMENTAL QUALITY

Registration Form – NDEQ Air Quality Update Workshops 2010

Registration Deadline – 2 weeks prior to event

Payment:

The registration fee of $10 must be made by check or cash (exact amount only please), either in advance or at the door. Select type of payment below.
If you’re paying the fee ahead of time, please submit your payment two weeks prior to the event. Print your registration form, and mail with your payment to NDEQ – Air Quality Division, P.O. Box 98922, Lincoln, NE 68509-8922

Instructions:

Click in each box to fill in your information.
Submit your registration 2 weeks prior to the workshop by using one of the following methods:
- Please print the completed form using your browser's print function (File menu - select Print)
- Mail the completed form to NDEQ – Air Quality Division, P.O. Box 98922, Lincoln, NE 68509-8922
- Fax the completed form to (402) 471-2909.
- To submit electronically select “Submit Form” button at the bottom of this page.

* Required Fields

Today's Date:	05/19/2013 10:34 AM
First Name*:	Last Name*:
Company*:
Address:
City:	State Zip Code
Phone*:
Email*:

Check the session you will be attending:

Grand Island – August 3 (Register By July 20)
Scottsbluff – August 4 ( Register By July 21)
Norfolk – August 10 (Register By July 27)
Lincoln – August 18 (Register By August 3)

(If attending more than one workshop you will need to include the fee for each workshop.)

Lunch, morning snacks and beverages will be provided. If you prefer a vegetarian lunch please check the box below.

Do you require a vegetarian lunch?

Yes

Will you be mailing the registration fee two weeks prior to the workshop

Yes, Check Number, if available

No, I will pay at the door

(exact amount only)

If you have any questions, please contact Tracy Thompson at (402) 471-4272 or tracy.thompson@nebraska.gov..

If you want to attend multiple sessions, Submit the first completed form and when you receive the "Thank You" message press the back button on you browser window, change the session location and resubmit.

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Nebraska.gov

Nebraska Department of Environmental Quality
1200 "N" Street, Suite 400
PO Pox 98922
Lincoln, Nebraska 68509
(402) 471-2186