Application for Membership & User Account

Name______________________________

Address ___________________________ __________________________________

Postal Code_________________________

Telephone Number ___________________

Date of Birth________________________

Mother’s maiden name________________ (This information will be used to uniquely identify you to the systems operator if you forget your password)

Password?__________________________ (Your password must contain at least two numbers or special characters (examples: #$%^&*) and be at least 6 characters in length)

In applying for membership, I assert the information provided above is truthful and accurate and that I have read and agree to abide by the membership and acceptable use policies of EASTMAN Community Computing Inc.

Signed____________________________

Date_____________________________

Parent or Guardian (if under 18) ________________________________

Please make cheques payable and mail to:
EASTMAN Community Computing Inc.
Box 612
Pinawa, MB
ROE 1L0