New Customer

Account Information

Username:	() Here are some suggestions for your username.* Click here to check for other suggestions.
Password:
Please type the password again:
Name:	(*)
Email:	(*)

Other Information

Agency Name
Address 1	(*)
Address 2
City	(*)
State	(*)
ZIP	(*)
Phone	(*)
Phone Ext.
Fax
URL
Other URL
Note:	Items below required for Registry State and Regional members.
Number of Inidividuals in Registry
Practitioner Registry?	No Yes
Trainer Registry?	No Yes
Training Approval/Registration?	No Yes
Contact Information	Entry of an initial contact member below is required. That individual will become the administrator of the agency account.
First Name	(*)
Last Name	(*)
Phone	(*)
Phone Ext.
TItle
Payment	You will be required to pay for your membership with a credit card using PayPal. If you do not wish to pay by PayPal, print this form and mail it (with your check) to: The National Registry Alliance PO Box 185653 Hamden, CT 06518-0653

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Payment Information

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The National Registry Alliance - PO Box 185653 - Hamden, CT 06518-0653