12th Annual Eastern NC Opioid and Gang Conference

Registration includes a $20.00 payment. Please begin the registration process by completing the information below about the registrant. Each individual must be registered separately. If you have questions please contact training@eastpointe.net

Note: upon completion of registration you will be re-directed for payment. If paying via agency check, please exit registration at the time of re-direction.


Please enter the first name of the individual registering.


Please enter the last name of the individual registering.


Please enter the Job Title of the individual registering.


Please enter the e-mail address of the individual registering.


Please enter only the last 4 digits of the social security number for the individual registering.


Please enter the Date of Birth of the individual registering.


Please enter the agency for which the individual registering will be representing.


Please enter the agency street address.


Please enter the agency state.


Please enter the agency zip code.


Please enter the best contact phone number for the registrant attending the conference.









Powered by Smartsheet Forms
Privacy Policy   |   Report Abuse
Your submission is being processed. Please do not close this browser window until complete.