Register an Agency

New Agency Registration

*Organization Type:			County:
Municipality/BOE:			*Agency:

* Are you the Records Manager for your organization? Yes No

(Records Manager role will permit you to submit disposition requests for multiple agencies and allow you to maintain agency and user profiles for multiple agencies in your organization)

Primary User Information

*First Name:

*Last Name:

*Login Name:

(must be between 6 to 15 characters in length.)

User Initials:

*Password:

(must have at least 6 alphanumeric characters. Cannot be same as Login Name.)

*Confirm Password:

*Pin Number:

(must have at least 4 digits.)

*Confirm Pin Number:

*Work Phone:

Ext:

*Email Address:

Agency Contact Information Copy Primary User Information

*First Name:		*Last Name:
*Job Title:		*Email Address:
*Address Line 1:		Address Line2:
*City:		*State:	*Zip:
*Work Phone 1:	Ext:	Work Phone 2:	Ext:

Records Manager Information

Copy Primary User Information Copy Agency Contact Information

First Name:			Last Name:
Work Phone:	Ext:

Terms and Conditions

I Accept*

*Signed By:

Signed Date:*

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