Non-Residential 1 on 1 Meeting Request Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Please select your area* This field is required.This information will help us with matching you with the correct representative.

Winnipeg, MB

Brandon, MB

Steinbach, MB

Pembina Valley, MB

Thunder Bay, ON

Dryden, ON

Other

5

Meeting Type* This field is required.Please state your prefered meeting method

Online

Phone Call

In-Person

7

Tell us why you are requesting this meeting* This field is required.