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Donor Information

 

Donor Contact information

Title:
  
First Name Last Name
   
 
Email Address  
 
Organization / Company
 
Position
 
Address
 
 
 
City Postal Code/Zip Province/State    
         
         
Telephone Fax Country    
       
Salutation First Name Last Name  
 
Salutation First Name Last Name  
 

Contact Name Contact Email Add Personal Message  
 

 

Privacy Statement

What information is collected and how it is used
Personal data collected through this site consists of information submitted voluntarily during the registration process, including your name, job title, organization, mailing address, telephone, fax numbers, e-mail address and emergency contact. Access to data is limited to staff of the Canadian Institute for the Relief of Pain and Disability to process registrations, organize the conference or to contact an emergency contact (should this be necessary).

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