Welcome!

Note: An asterisk (*) indicates a required field.

I plan to attend the Interdepartmental Tribal Justice, Safety & Wellness Government-to-Government Consultation, Training and Technical Assistance Session scheduled for Tuesday, December 9 at the Palm Springs Convention Center.*
Yes    No

I plan to attend the all-day grant writing workshop scheduled for Monday, December 8, at the Palm Springs Convention Center.*
Yes    No

Prefix
Mr. Ms.

First Name*

Last Name*

Title

Organization*

Department

Address 1*

Address 2

City*

State*
Please select from this list. Alabama Alaska American Samoa Arizona Arkansas California Colorado Commonwealth of the Northern Mariana Islands Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code*

Phone*

Cell Phone

Best Time to Contact
Morning Afternoon Evening

Fax

E-mail

What is your Tribal affiliation?

Please identify your one primary function at this conference:*

If "Other," describe here:

Please select the one category that best describes your organization type:*

Please select the one category that best describes your personal area of work involvement:*

Pursuant to the Americans with Disabilities Act, do you require specific aids or services?
No
Yes
If so, please describe:

Do you have any special dietary needs?
No
Yes
If so, please describe:

Contact information will be used to compile a participant list for distribution at the conference. If you do not wish to be included on the participant list, please check below.
Do not include my information on the participant list.