Mr. Ms. Mrs. Miss. Dr.
FIRST NAME:
LAST NAME:
ORGANIZATION:
STREET ADDRESS:
CITY/TOWN:
PROVINCE:
POSTAL CODE:
TELEPHONE:
FAX:
EMAIL:
COMMENT:
This personal information is being collected under the authority of The University of Manitoba Act. It will be used for the purposes of mailing information, and communication with the participant. It is protected by the Protection of Privacy provisions of The Freedom of Information and Protection of Privacy Act. If you have any questions about the collection contact the FIPPA/PHIA Coordinator’s Office, University of Manitoba Archives & Special Collections, 331 Elizabeth Dafoe Library, Winnipeg, MB, Canada R3T 2N2 (tel. 204-474-8339).