UHCL E-Commerce

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UHCL E-Commerce: Account Creation Form

First Name(Length should not exceed 20 characters):

Last Name(Length should not exceed 30 characters):

Email Address:

Confirm Email Address:

Password:

Passwords are case-sensitive.It is recommended that you provide a secure password .

Confirm Password:

Security Question:

The security question and answer will be used during password resets and for account recovery purposes.

Security Answer:

Answers are notcase-sensitive.

Confirm Answer:

Please provide the following information. This information will be used as your default billing information, and may be used for communication purposes regarding any registrations or purchases. After your account registration is complete, you will be be able to update this information as necessary.

Phone Type:

Phone Number:

Address Type:

Street(Length should not exceed 50 characters):

City:

State:

Zip:

Do you have any additional registrants?

If you plan to register family members, co-workers, or anyone other than yourself for a scheduled event, please select Yes.

Yes No

Please provide the names of the individuals that you intend to register for events.

Action

First Name

Last Name

Email Address

Date of Birth

Click the "Add Registrant" button to add an additional registrant (family member, co-worker, etc.)

Account Verification Notice:

An email verification step is required before you can login to your newly created account.

A verification email will be delivered to your email address containing a link that you must use to confirm and activate your account.

Failing to complete this step will prevent you from logging in.

I understand that I must verify and confirm my account

Cancel

Template Application

UHCL E-Commerce: Account Creation Form