PERSONAL INFORMATION

 
20% of survey complete.

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* 1. First Name:

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* 2. Last Name:

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* 3. Telephone Number:

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* 4. Email Address:

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* 5. Self-Identify as female:

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* 6. Manitoba Resident*:

*For the purposes of this application, a Manitoba Resident shall be defined as a Canadian Citizen or Permanent Resident of Canada who, at the application deadline, meets the following description:
· has resided continuously in Manitoba for any two-year period while attending a Manitoba high school

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* 7. Permanent mailing address (Street/P.O. Box):

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* 8. City/Town:

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* 9. Province:

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* 10. Postal Code:

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