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Registration

CEU_Registration

User Registration

*Note: Membership to this portal is Public. Once your account information has been submitted, you will be immediately granted access to the portal environment. All fields marked with a red arrow are required. - (Note: - Registration may take several seconds. Once you click the Register button please wait until the system responds.)

Login Info

UserName:	User Name Required
Display Name:
Password:
Confirm Password:	Password must match

Registration Info

First Name:	*First Name is required
Middle Name:	*Middle Name is required
Last Name:	*Last Name is required
Date of Birth:	*Date of Birth is required
Address:	*Address is required
City:	*City is required
State:	*State is required	Zip:	*Zip is required
Phone Home:	*Phone Home is required
Phone Business:	*Phone Business is required
Phone Cell:
Email	*Email is required
PIN# or last 4 digits of Social:	*PIN# or 4 digits of Social is required
Company Name:
License Number on ID Card: