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Name
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First Name
Last Name
Email
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Ethnicity
(Required)
Black or Sub-Saharan African (such as African American, Afro-Caribbean, Black Canadian, Ethiopian, Nigerian)
South-East Asian / East-Asian (e.g., Burmese, Cambodian/Kampuchean, Laotian, Malaysian, Thai, Vietnamese, Indonesian, Chinese, Japanese, Korean, Filipino)
South Asian/East Indian (e.g., Bangladeshi, Pakistani, Indian from India, East Indian from Guyana, Trinidadian, Sri Lankan, East African)
Arab or Middle Eastern (such as Non-White West Asian, Non-White North African, Iranian/Persian, Lebanese, Moroccan)
Non-White Latin American (including indigenous persons from Central and South America)
Person of Mixed Origin (with at least one parent in one of the racialized groups listed above)
Indigenous person
Other
Please specify your ethnicity
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Which term(s) best describes your gender identity?
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Please check all that apply
Transgender
Gender variant
Gender non-conforming
Genderqueer
Non-binary
Two-spirit
Cisgender woman
Cisgender man
Prefer not to disclose
Other
Please specify your other gender identity.
(Required)
Include one credential here so we can verify you .
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Licensed
Pre-license or under supervision
No license
License number
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License province
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Lincense expiration date
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