Product Order Form

TB Program Manager's Workshop: A Web-Based Course Application Form

Background/Contact Information

*First Name:
*Last Name:
Degree:
*Title:
Affiliation:
Department:
*Address 1:
Address 2:
*City:
*State:
*Zip/Postal Code:
*Country:
*Phone:
Fax:
*Email Address: (for order confirmation)	(Valid e-mail addresses only)
Your supervisor will receive an emailed copy of your application and will need to certify that you are eligible to take this course. Instructions will be included in this e-mail.
*Supervisor's Email Address.

Job History and Responsibilities

Percentage of work time devoted to TB:
Years of supervisory or managerial experience:
Do you currently supervise or manage other staff members?
if yes, how many?
Briefly describe your duties:
Please describe your workplace:	Local Health Department City Health Department State Health Department

Needs and Expectations for Course

What specific knowledge and skills do you hope to gain from this course?
As a service, we may provide an attendee list of this course to each participant. If you DO NOT wish to be included on this list, please check this box.