Palo Verde Registration and Badging Info

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					                                  NAPM-AZ and APICS Phoenix Chapter
                                               Joint Tour:
                               APS Palo Verde Nuclear Generating Station
                                              May 13, 2011
                                      Registration Information and
                         Required Information for Security Screening and Badging

Please complete the information below. Incomplete forms or empty fields can not be accepted.

                         Full Legal Name:
                      (First, Middle, and Last)
                Social Security Number:
    (or Passport Number for Non US Citizens):
                          Citizenship:
                  Membership Number:               NAPM#                 APICS#       Expires:
                        Date of Birth:
                              Gender:
                       Email Address:
                    Complete Address:
    (Home or Business, Include City/State/ZIP)
                          Home Phone:
                          Work Phone:
                            Cell Phone:
                             Employer:
                              Job Title:
     Do you have any Artificial Joints?               No    Yes , explain:
       Do you have any metal medical                  No    Yes , explain:
                             implants?
    Have you had any Nuclear Medical                  No    Yes , explain:
         Treatments That Involved the
  Ingestion or Injection of Radioactive
        Materials in the Last 30 Days?
                Comments/Questions:


To complete the registration process for this joint plant tour, please send this form by May 6th at 5:00
p.m. to:
              NAPM-AZ
              Email: NapmArizona@cox.net           link:(NapmArizona@cox.net)
              Fax: 602.493.2006

Tour spots are limited for each organization and are on a first-come, first-served basis. NAPM or APICS
members are given preference over non-members. You will receive a confirmation relating to your
tour status before the event (accepted or waitlisted).

                                                  www.apicsphoenix.org
www.napmaz.org

				
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