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Wednesday 02/05/2025 01:40 AM CST
Registration Step 1 of 2 - Personal Information
The
*
(in red) indicates required fields. (Note: When the Add/Save button is present, all fields with
*
are only required when selecting Add/Save for that section.)
Please provide the following information to get started!
*
First Name
First Name is a required field.
The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"].
*
Last Name
Last Name is a required field.
The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"].
*
Birth Date
Birth Date is a required field.
Birth Date is not valid or in the correct format. Enter a valid value in the format 'MM/DD/YYYY'.
The date cannot be greater than the 12/31/2299.
*
Last 4 of SSN
Last 4 of SSN is a required field.
Last 4 of SSN is not valid or in the correct format. Enter a valid value in the format '9999'.
*
Delegate Code
Delegate Code is a required field.
Delegate Code is not valid or in the correct format. Enter a valid value in the format '99999999'.
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