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* 1. First Name

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* 2. Last Name

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* 3. Confidential Email Address

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* 4. Telephone number

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* 5. City

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* 6. Province/Territory

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* 7. Practice you're associated with (include name & address)

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* 8. Job title

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* 9. Please include either a YouTube or Vimeo video link with your submission (please upload your recording to your preferred video platform first, then share the link here)

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* 10. Do you consent to your video being shared and showcased online?

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* 11. Do you consent to receive emails including news, articles and event updates from ROI Corporation?

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