REGISTRATION FORM Safety and Chemical Engineering Education 2016 Faculty Workshop Chevron Energy Technology Company, Richmond, CA. Aug 21-24, 2016 Please complete this form, filling in the appropriate form fields return to Ronald J. Willey by June 15, 2016 Reservations are first come, first serve, 25 spaces are available Meals and room costs at the workshop are covered by SACHE Email to: Attendee Information First: MI: Last: Nickname for badge: University: Special Meal or Related Requests: Emergency Contact: Name: Phone: Your Contact Information Address: City: ST: Zip: Country: Cell Phone: Email: Hotel Information: Reservations will be made for you through this form: Hotel: Please check the nights that you Additional Information Needed: need a room Courtyard Richmond Berkeley Satuday (8/20/16) ** Citizenship? 3150 Garrity Way Sunday Night (8/21/16) Richmond, California 94806 USA Chest Size for Nomex Suit? Monday Night (8/22/16) Length Reg, Long)? IMPORTANT: Tuesday (8/23/16) () Your room is reserved thru this Do you have Steel Toed Shoes? Wednesday Night (8/24/16) ** form: If No, Shoe size (USA measure)? ** You will need to cover Sat & Wed nights if you need to stay early or late. Airline Information: This information can be added later…we will have a shuttle at SFO 3 PM 8/9 Arrival: Departure: Airline Airline Flight Number Flight Number Date Date Time Time any questions please contact ron Willey, 781-492-4956, or by email at r.willey@neu.edu
REGISTRATION FORM Safety and Chemical Engineering Education 2016 Faculty Workshop Chevron Energy Technology Company, Richmond, CA. Aug 21-24, 2016 Please complete this form, filling in the appropriate form fields return to Ronald J. Willey by June 15, 2016 Reservations are first come, first serve, 25 spaces are available Meals and room costs at the workshop are covered by SACHE Email to: Attendee Information First: MI: Last: Nickname for badge: University: Special Meal or Related Requests: Emergency Contact: Name: Phone: Your Contact Information Address: City: ST: Zip: Country: Cell Phone: Email: Hotel Information: Reservations will be made for you through this form: Hotel: Courtyard Richmond Berkeley 3150 Garrity Way Richmond, California 94806 IMPORTANT: Your room is reserved thru this form: Please check the nights that you need a room Satuday (8/20/16) ** Sunday Night (8/21/16) Monday Night (8/22/16) Tuesday (8/23/16) Wednesday Night (8/24/16) ** ** You will need to cover Sat & Wed nights if you need to stay early or late. Additional Information Needed: Citizenship? USA Chest Size for Nomex Suit? Length Reg, Long)? () Do you have Steel Toed Shoes? If No, Shoe size (USA measure)? Airline Information: This information can be added later…we will have a shuttle at SFO 3 PM 8/9 Arrival: Departure: Airline Airline Flight Number Flight Number Date Date Time Time any questions please contact ron Willey, 781-492-4956, or by email at r.willey@neu.edu
Registration_Form_SACHE_2016_Faculty_Workshop.docx