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CSGNA Speaker Agreement

Contact Information & Activity

1. Contact Information *This question is required.

First Name

Last Name

Title

Institution

City

Province

Email Address

Phone Number

2. What is your role in the CPD activity? *This question is required.

Member of the planning committee
Moderator
Speaker
Author
Facilitator
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.