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SECTION A: Provider Profile Provider Name:Physical Address:Province:Code:Postal Address:Postal Code:Contact Details:Telephone Number:Fax Number:Email Address:Website (if any):Contact Person Details:
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Enter the current month using two digits (e.g. 09 for September).
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Enter the current day using two digits (e.g. 15 for the 15th).
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Enter the current year using four digits (e.g. 2021).

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Anyone who needs to accurately record the current date can use mmddyyyy format.

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