Open Health Tools Individual Contributor Questionnaire

To be completed by each new contributor. This questionnaire is to be completed by each personseeking Contributor status for an Open Health Tools project as an individual. If you have anyquestions, please send an email to the Open Health Tools Management Office. Fields marked with anasterisk are mandatory.

* Have you read and do you agree to abide by the terms of the Open Health Tools Terms of Use?

Yes No
First Name:*
Last Name:*
Employer Name:*
Address:*
City:*
Province/State:*

Postal Code/ZIP:*
Country:*
Email Address:*
  You must provide us with either a phone number, a mobile number or both.
Phone Number: *
Mobile Number:*
Fax Number:
Open Health Tool Project(s)
Please enter the result of the following mathematical question: 2028 times 78
You may either print and mail this form or submit the form via email. Depending on your browser and email application, you may encounter problems transmitting this information through the use of the "Send form via email" button. If this happens, please copy the form into an email, complete it and sent ot to oht-mo at openhealthtools.org, or print the form and mail it to the address below.

Mailing Address
Open Health Tools, Inc.
11782 Rose Beach Line
Morpeth, Ontario
N0P 1X0
Canada