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Account Registration

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* Registration Type:

Setup Person Setup Organization (Business/Exempt Agency/Law Firm/Government Agency)

Organization Information

*Organization Name:

*Type:

* Primary Email:

Alternate Email1/Email2:

*Address 1/2:

*Country/City

*State/ Zip Code:

Phone # (Format ###-###-####):

Extension:

Copy Contact Information to Administrator

Administrator

*Role:

Arizona ID:

ID Type:

*User Name:

Password must be between 6 and 16 characters, with at least 1 number

*Password:

*Re-type Password:

*Security Question:

*Security Answer:

*First:

Middle:

*Last

Suffix

Name: