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Name
Prefix
First Name*
Middle Name
Last Name*
Contact Information
Street Address*
City/Town*
Country*
Province*
State*
Postal Code/Zip Code*
Preferred Telephone Number

(###) ###-####
Professional Information
What is your main profession?*
What is your primary specialty or area of expertise?*
What is your primary specialty as a physician?*
What Type of Professional Are You?*
What is your Speciality?*
Are you a member of the Association of General Dentistry (AGD)
- Yes
- No
What is your AGD Number?*
Do you have a faculty appointment OR are you a student at the University of Manitoba?*
- Yes
- No
What is your primary College affiliation in the Faculty of Health Sciences?
Are you primarily a:
Year of first U of M academic appointment
What is your teaching setting?
In which educational programs have you primarily taught over the last 5 years?
Please list the multiple programs in which you teach
Additional Information
What is the primary geographical setting of your work?
What is the primary practice settings in which you work?
In what year were you first licensed for practice?
Account Information
Primary Email*
This email address will be used to login. Correspondence and notices for events that you have registered for, will be sent to this address.
Enter Email Confirm Email
Secondary Email
Add a secondary email address in case we receive a delivery failure on your primary email address. Please note this address cannot be used to login to your profile.
Enter Email Confirm Email
Password*
Enter Password Confirm Password

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After you have created your account and are logged in, click on My Event Cart at the top right of the page to complete any event registrations in progress.

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Create New User Account

Name

Contact Information

Professional Information

Additional Information

Account Information

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