Registration – Connecticut AETC

Name*

First Last

Email*

Username*

Password*

Enter Password Confirm Password

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Clinic/Agency/Institution/Organization*

Work Postal Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Your Primary Profession/Discipline*

Select One

Specify Primary Profession/Discipline*

Please write your Primary Profession/Discipline

Highest Degree Attained

What is your gender?

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Are you of Hispanic or Latino/a origin?

What is your racial background?

Select all that apply.

What is your age?

How many years have you been providing health care services?

Are you a supplier of care for HIV?

How many years have you been providing services to those with HIV?

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