First Name

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* 1. First Name

Last Name

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* 2. Last Name

E-mail Address

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* 3. E-mail Address

Institution / Organization / Company

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* 4. Institution / Organization / Company

Type of Institution / Organization / Company (Choose all that apply)

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* 5. Type of Institution / Organization / Company (Choose all that apply)

Professional Role / Title and Department if applicable

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* 6. Professional Role / Title and Department if applicable

Will you be attending the light lunch (12:45 pm to 1:30 pm) following Dr. Alan Bernstein's Lecture at U Ottawa on Tuesday, October 31, 2017?

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* 7. Will you be attending the light lunch (12:45 pm to 1:30 pm) following Dr. Alan Bernstein's Lecture at U Ottawa on Tuesday, October 31, 2017?

Have you attended previous Friesen Prize Program events?

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* 8. Have you attended previous Friesen Prize Program events?

Will you review the FCIHR web site:  www.fcihr.ca  ?

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* 9. Will you review the FCIHR web site:  www.fcihr.ca  ?

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