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Name
Prefix*
First Name*
Middle Name
Last Name*
Contact Information
Street Address*
City/Town*
Country*
Province*
State*
Postal Code/Zip Code*
Preferred Telephone Number*

(###) ###-####
Professional Information
What is your main profession?*
What is your primary specialty or area of expertise?*
What is your Speciality?*
Are you a member of the Association of General Dentistry (AGD)
- Yes
- No
What is your AGD Number?*
What is your primary specialty as a physician?*
What Type of Professional Are You?*
Do you have a faculty appointment OR are you a student at the University of Manitoba?*
- Yes
- No
What is your primary College affiliation in the Faculty of Health Sciences?
Are you primarily a:
Year of first U of M academic appointment
What is your teaching setting?
In which educational programs have you primarily taught over the last 5 years?
Please list the multiple programs in which you teach
Additional Information
What is the primary geographical setting of your work?
What is the primary practice settings in which you work?
In what year were you first licensed for practice?
Account Information
Primary Email*
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Secondary Email
Add an secondary email address to have a copy of your registration details emailed to: an assistant, an alternate workplace, etc. Please note this address cannot be used to login to your profile.
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