CARBON MONOXIDE SURVIVORS ASSOCIATION, international
                              (COSA,i)


                        'REGISTRATION FORM'


                            Page 1 of 2


        Please print out both pages for your use to register with COSA,i


        OR, IF NO PRINTER AVAILABLE SIMPLY PRINT THE INFORMATION ASKED FOR ON 
        PLAIN WHITE PAPER AND SEND IT TO ADDRESS SHOWN ON PAGE 2 OF THIS FORM...


I.    See MEMBERSHIP page above and tell us the membership classification 
      you are applying for (check one or more of the following classifications,
      all as may be applicable to your circumstances).

_____a.     'GENERAL SURVIVOR' MEMBER;
_____b.     'PUBLIC INTEREST' MEMBER;
_____c.     'COMMERCIAL INTERESTS' MEMBER;
_____d.     'ACADEMIA' MEMBER;
_____e.     'CONSULTING' MEMBER.

II.   Your name (or company/group name) __________________________________ 

III.   Your e-mail address: ______________________________________________

IV.   Your mailing address: ______________________________________________
                                     (street or post office box number)

                            ______________________________________________                                                                                          
                            (city/town.........., state..........zip code)
 
V.  Your home___ or business___phone number________  _______  ____________
                                          (area code)
                                                 
                            ___fax number  ________  _______  ____________ 
                                          (area code)

VI.  If you will be a 'GENERAL SURVIVOR' member, please tell us if your CO involvement was 
              a. an acute one time exposure to CO ........_____ 
              b. a chronic (several episodes) exposure to CO ........_____  
              c. Or, both of the above types of exposure to CO ........_____

                    NOTE:  We will be collecting much more data relating to each 
                    member's individual CO experience(s) later on.  Watch this web site 
                    for future questionaires, etc. in this regard.