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R1C1W12
Pelvic Floor Disorders Consortium Membership Sign-Up Form
Please provide the following contact details:
First Name
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Last Name
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Company
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Address
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Address 2
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City
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State
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Alabama
Alaska
American Samoa
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Arkansas
Armed Forces Africa, Canada, Europe, Middle East
Armed Forces Americas
Armed Forces Pacific
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Canal Zone
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Zip Code
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Aruba
Australia
Austria
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Bahrain
Bangladesh
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Basutoland
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bophuthatswana
Borneo
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Terr
Brunei
Brunei Darussalam
Bulgaria
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Burma
Burundi
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Cambodia
Cameroon
Canada
Canal Zone
Canary Islands
Cayman Islands
Caymen Islands
Central African Republic
Central America
Chad
Channel Island
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Dem Republic of)
Cook Island
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curacao
Cwth. Ind. St.
Cyprus
Czech Republic
Dahomey
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Is (Malvinas)
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Terr
Gabon
Gambia
Georgia
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Ghana
Gibraltar
Gibralter
Granada
Greece
Greenland
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Guadeloupe
Guam
Guatemala
Guernsey
Guinea
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Guyana
Haiti
Heard Is and McDonald Is
Holland
Holy See (Vatican City)
Honduras
Hong Kong
Hungary
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Indonesia
Iran
Iran, Islamic Republic of
Iraq
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Isle of Man
Israel
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Jamaica
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Kenya
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Monace
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Nigeria
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Panama
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Poland
Portugal
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Qatar
Republic of Georgia
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Reunion
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Samoa
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Santa Lucia
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Scotland
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Slovinia
Solomon Islands
Somali Republic
Somalia
South Africa
South Georgia and the SSI
South Korea
South Sudan
Southwest Africa
Spain
Sri Lanka
St Vincent and Grenadines
Sudan
Surinam
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Tasmania
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Tokelau
Tonga
Trinidad
Trinidad and Tobago
Tunisia
Turkey
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Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United Kingdom
United Rep of Tanzania
United States
Upper Volta
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Vietnam
Virgin Islands
Virgin Islands, British
Virgin Islands, US
Wallis and Futuna
Western Sahara
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Yemen
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Zambia
Zimbabwe
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Email
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Please provide valid email
MobilePhone
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Degrees
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Subspecialty
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Which of these affiliated societies are you a member of?
ASCRS
AUGS
ICS
IUGA
SAR
SGS
SUFU
UK Pelvic Floor Society
May we contact you with information and updates from the consortium?
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Yes
No
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