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Individual Application This application is intended for members who are not part of a member organization. Before completing this application, please be sure your organization is not already a member. Please be sure you are not already a member by using your email address to check for a password. Required fields marked with an asterisk (*) * First Name: Middle Name: * Last Name: Title: Address: City: Country: US Canada * Email: Work Phone: Mobile Phone: Fax: State/Zip: ALAKAZARCACOCTDCDEFLGAHIIAIDILINKSKYLAMEMDMAMIMNMSMOMTNENHNJNMNYNVNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Province/Postal: AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

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© 2006 UMR-ACUHO The purpose of UMR-ACUHO shall be to promote and provide an environment of full opportunity and service for all persons regardless of ethnicity, creed/religion, age, gender, disability, sexual/affectional orientation, or any human circumstance. The Association will not arbitrarily discriminate in its programs, procedures, or activities.