The College of Midwives of Manitoba (CMM), Student Application for Registration Subscription Personal Info

Student Application for Registration Personal Info

Personal Information

First Name *

Last Name *

Middle Name (Optional)

Preferred Name

Previous Name

Date of Birth

Gender

Identify a primary email address; this is the email that the CMM will use to communicate with you. You may choose to use your personal or work email address. If you chose your work email address, we encourage you to provide an alternate email address as well.

Primary Email *

Alternate Email

Home Mailing Address

Address Line 1 *

Address Line 2

City *

Country *

Province/State *

Province/State

Postal/Zip *

Provide a primary personal phone number that the CMM may use to contact you.

Phone (Primary) *

Phone (Additional)

(Home Street Address: Provide if different than home mailing address.)

HOME STREET ADDRESS

Street Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

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Username *

Password *

Password Confirmation *