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    Name of First Nation:

    Mailing Address:

    Telephone Number:

    Fax Number:

    Current Caseload (approximately):

    Staff Person's Name

    Title/Position

    Telephone and Extension Number

    Email Address

    Software User

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes

    Yes