NOSM/ROMP UHIP Registration

If you have any questions about this form, please contact Chris Gallinger by e-mail at 'clgallin@lakeheadu.ca'.

First Name *

Last Name *

Affiliation

Address *

Country *

Address 1 *

Address 2

City *

Province *

Postal code *

Phone (with area code) *

E-mail Address *

Birth Date *

Gender *

Male

Female

Cost for UHIP:
1 placement: $51 (HST Included)
2 placements: $102 (HST Included)

Placement Start Date *

Month

Day

Year

Placement End Date *

Month

Day

Year

NOSM/ROMP UHIP