Organization:(Enter up to 70 characters maximum)

What Qualifies and Differentiates This Provider:(Enter up to 3 lines, 205 characters maximum)

Customer Satisfaction Policy:(Enter up to 3 lines, 205 characters maximum)

Contact Person: First Name: Last Name:

Street Address:(Enter up to 70 characters maximum)

City:(20 max) State/Province:(20 max)

Zip Code:(10 max)

Country: USA Australia Canada France Germany Mexico Netherlands United Kingdom

Home Page (leave blank if none):

E-Mail:

Phone: Fax:

How would you like to receive requests for registration/purchase/information? (note: charges are per transmittal)

E-Mail (free) Fax ($2) US Mail ($3)

Choose Provider Password (7-10 characters, letters and/or numbers, case sensitive. Please make a record of this password as you will need it each time you add a resource.):

Entered By: Phone:

E-Mail: