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Contact Information:
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Name of Member Society:
*
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First Name:
*
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Last Name:
*
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Organization/Employer:
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| Department: |
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| Position/Title: |
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Note: The following address is used for billing purposes.
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Business Address:
* |
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City:
*
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Province:
*
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| Postal Code(no space):
* |
Country: |
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| Phone:
* ex. 999-999-9999 |
Fax: |
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| Email:
* |
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Please note: As a result of the Federal Privacy Legislation (Bill C6), you are not obligated to provide us with your birth date or home address.
Home Address |
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Province: |
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| Postal Code: |
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| Phone: |
Fax: |
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| Email: |
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Address to be used for Society mailings and Directory listing:
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