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Membership Application Form
The Executive Secretary
Oral Health Pacific Islands Alliance
Dear Executive Secretary
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I want to apply for membership as:
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Full Member (FJ$300)
Associate member (FJ$100)
My details are as follows:
Name (First, Last Name):
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Your answer
Preferred Title:
Mr
Ms
Dr
Other:
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Employer :
Your answer
Position :
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Your answer
Qualifications :
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Your answer
Country of Residence
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Your answer
Phone(Country code and Number) :
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Your answer
Mobile No (Country code and Number):
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Your answer
Email :
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Your answer
Primary place of work
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Your answer
Phone :
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Your answer
Preferred mode of communication:
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Email
Phone
I agree to abide by the rules and regulations of the Oral Health Pacific Islands Alliance that are in force and pay all the dues as is required in a timely manner.
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