#INCLUDE filename="include_head.html">
<#INCLUDE filename="include_header.html">
<#STATUS>
<#FORMSTATE>
New User Registration for ILLiad
User Information
First Name
(required)
Last Name
(required)
ID Number
(required)
Email Address
(required)
Daytime Phone
(required)
Mobile Phone
Department
<#OPTION name="custom" groupname="Department" selectedValue="<#PARAM name='Department'>">
Status
(required)
<#OPTION name="custom" groupname="StatusGroup" selectedValue="<#PARAM name='StatusGroup'>">
Delivery Location
<#OPTION name="custom" groupname="NVTGC" selectedValue="<#PARAM name='NVTGC'>">
Address Information
Address Line 1
(required)
Address Line 2
Address City
(required)
Address State
(required)
<#OPTION name="custom" groupname="State" selectedValue="<#PARAM name='State'>">
Address Zip
(required)
Create Logon Information
Username
(required)
Password
(required)
Passwords must be at least eight characters long and contain a lowercase letter, an uppercase letter, and a number.
Re-enter Password
(required)
Submit Information
Cancel - Return to Logon page
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