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Name:	(*)
Email:	(*)

Institution/Organization Name	(*)
Address 1	(*)
Address 2
City	(*)
Province	(*)
Postal Code	(*)
Country	(*)
Institution Phone 1
Institution Phone 2
Fax
Website
Representative Name	(*)
Representative Title
Representative Email
Representative Phone
Is your institution affliated with another post-secondary institution?	Yes No
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Is your institution?	Provincially Funded Privately Funded Other
If Other, please specify
Is your institution a member of	Universities Canada Colleges and Institutes Canada Other
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