Participant Application - The Association of Occupational and Environmental Clinics

Name of applicant(Required)

First Last

Name of hospitals

Title

Department

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office phone

Cell phone

Fax number

Email(Required)

Enter Email Confirm Email

Number of licensed beds

Please enter a number greater than or equal to 1.

Are you new to EPINet?

Yes

# of years you have been using EPINet?

Starting year?

Personal email address

The firewall at your hospital usually prevents the delivery of the EPINet attachment. A personal email address, such as hotmail, yahoo, etc. does not have a firewall and will allow the EPINet attachments to be delivered.

Phone

This field is for validation purposes and should be left unchanged.