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