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1. Chicago Cancer Rights Conference 2012 - Registration Form

Thank you for your interest in attending the Cancer Legal Resource Center's Chicago Cancer Rights Conference on September 7, 2012.

To register for this event, please complete the registration form below. Please complete one registration form per person.

If you have questions about the registration process or the Conference, please email CLRC@LLS.edu or call 773.750.3063.

For more information about the Conference, including the agenda and hotel information, please visit www.CancerRightsConference.org.

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* 1. First Name

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* 2. Last Name

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* 3. Suffix

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* 4. Organization

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* 5. Do you want your "Organization/Company" to be displayed on your name badge?

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* 6. Title

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* 7. Do you want your "Title" to be displayed on your name badge?

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* 8. Address

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* 9. City

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* 10. County

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* 11. State

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* 12. Zip Code

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* 13. Phone Number xxx-xxx-xxxx

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* 14. Alternate Phone Number xxx-xxx-xxxx

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* 15. Email address
(Please note: If you do not provide an email address, we will send you conference information by mail.)

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* 16. Alternate Email Address

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