Contact Information

First Name:
Last Name:
Organization:
Street Address1:
Street Address2:
City:
State:
Country:
Zip Code:
Phone Number:
Comments:

In order to verify who you are over the phone if you request changes to your account, please pick a question below and provide the answer.

Question:	What is your mother's maiden name? What city were you born in? What high school did you graduate from? What is your first pet's name? What is your date of birth? What is your favorite sports team?
Answer:

Which category below best describes your group (Check one of the following choices)

Economic Development
Education
Government - Federal
Government - Local
Government - State
Health Care
Human Services
Library
Public Safety
Public Services
None of the Above

Flex Account Name

As group administrator, you need to choose a name for your Flex account. This will be the account name that members of your group will enter when they do their individual flex member registrations. This name will also be used as part of the address for your world wide web home page (e.g. http://dialoregon.net/~abc-org) if you choose to use this feature.

Please enter an account name that

• is three to eight characters long
• is all lower case (no capital letters)
• consists of only letters, numbers, and/or dashes (-)
• is a reflection of your group's name

Flex Group Administrator Email

This is the email address where we will send all administrative announcements and other information regarding your Flex account. If you do not know the email address at this time, you may leave this field blank.

Email Address:

Number of Flex Members

Flex accounts are designed to allow multiple users to share from a pool of online hours per month. Please enter the number of members for this Flex account. Additional members can easily be added at any time.

Number of Flex Members:

Dial-Up Usage

There are two options for purchasing dial-up time:

• The Flex group can pay for 100 hour blocks of time per month, which allows all Flex members to share the "pooled" time. Each 100 hour block is $300/year.
• The Flex group can pay for its dial-up usage at 30 cents/hour on a monthly basis.

This is the first of two forms you must complete in order to register for your Online Services Flex Account. Your account will not be activated until you complete and submit this form and the subsequent password form.