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| REGISTRATION FORM - Please
complete as much as possible to streamline sign up process |
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| Background Information |
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| Employment Information |
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| Do you require Professional Indemnity Insurance? Yes No |
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| I confirm that I have not previously been the subject
of a claim that would otherwise be covered by the Professional
Indemnity Insurance Policy and that after reasonable enquiry I am not
aware of any claims or circumstances that might give rise to a claim
under the Professional Indemnity Policy. |
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