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cancervic Sign Up Information

Last Updated:
5/7/2020 1
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Email Address


Your Name

 First Name, Last Name

Your Address

 Home Address, State, Region, Postcode

Phone Number

 Mobile Phone

Post-Registration Data

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Membership Emails

Below is a sample of the emails you can expect to receive when signed up to cancervic.

Cancer Council Victoria Logo

Thank you for your interest in joining Cancer Council Victoria's Clinical Network.

We have received your membership form with the details below and will be in touch with more information soon.

Personal Details
Title: Mr
First name: Christopher
Last name: Harris
Organisation name: Jon
Job title: Mr
Work phone: Jon
Mobile phone: 07968844605
Email : neighbor51106@
Secondary email: neighbor51106@
Gender: Mark Male
Profession/s: Jon

Address: Organisation
Department: 153 Langham Road
Work address: 190 Langham Road
Mailing address: 225 Langham Road
Suburb: Jon
Post code: N15 3NB

Address: Secondary organisation
Organisation: 208 Langham Road
Job title: Mr
Department: Jon
Phone: Jon
Work address: 156 Langham Road
Suburb: Jon
Postcode: N15 3NB
Mailing address as above?: True
Mailing address: 133 Langham Road
Suburb: Jon
Post code: N15 3NB
Do you wish to receive information from other units within Cancer Council Victoria? : True

Area of practice
What is your area of practice?: Lung Cancer
Other areas of practice: Jon

Areas of interest
What are your interest areas?: Health policy
Other areas of interest: London
Qualifications: Jon
Professional affiliations: Jon
Years of practice: 10-20 years

Personal Assistant/Secretary Details
Organisation: Jon
Preferred title: Mr
First name: Elijah
Last name: Hall
Work phone: Jon
Email: neighbor51106@

Other information
Notes: neighbor51106@

For any queries please contact or phone 9514 6304.

This email (including any attachment/s) is intended for the named recipient(s) only and may contain privileged and confidential information. If you have received this email in error, please inform the sender and delete this email and any copies immediately. If you are not the intended recipient of this email, any unauthorised use is expressly prohibited. Cancer Council Victoria provides no guarantee that this communication is free from virus or that it has not been intercepted or interfered with. Cancer Council Victoria may collect personal information about you so that we can perform our functions and activities including providing quality services to you. For more information about how we may handle your personal information, please see our Privacy Policy at

First name
Last name
Phone (mobile)
Home address
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Please enter a valid email addressGender (optional)
Prefer to self-describe
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Data Name Data Type Options
  Text Box
First name   Text Box
Last name   Text Box
Title   Text Box
Email   Text Box
Phone (mobile)   Text Box
Home address   Text Box
Region   Text Box
Postcode   Text Box
Gender   Text Box
  dropdown Please select
  option Please enter a valid email addressGender (optional)
  option Female
  option Male
  option Prefer to self-describe
  dropdown Please select
  dropdown Please select
  dropdown Please select

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Comment on: 01/09/2020