Online Application Form

Please choose the local dial up access you require.	215 Area Dial Up Access 610 Area Dial Up Access 609 Area Dial Up Access 856 Area Dial Up Access
Name
Organization
Address
City
State	Zip
Country
Phone

Please specify a user name which you will use on our system. The username must consist of 2-8 lower case letters and not contain any punctuation.  

Please specify a password which you will use to gain access to our system.

The password MUST be constructed to meet the following requirements:

• The password must have eight characters.
• The password must contain at least two alphabetic characters, at least two numeric characters, and at least two special characters (punctuation).
• The password must not resemble the user's login name or any reverse or circular shift of that login name.
• The password must not contain the user's initials.
• The characters of the password must not be able to be re-arranged to form a name, place, thing, or any word that can be found in the dictionary.

The password supplied below must meet each requirement stated above—no exceptions.

Password:
Password (enter again for verification):

DESCRIBE YOURSELF (Optional)

Are you one or more of the following:
Person with HIV/AIDS
Health Care Professional
AIDS Service provider
AIDS activist
AIDS researcher
Fuller Information Exchange
None

Race: Please specify African descent Latino/Latina Caucasian Asian-Pacific Islander American Indian Multi-Racial Other

What is your current age? Under 18 18-30 31-40 41-50 51-60 61-70 71-80 Over 80

Please click on the submit button one time only. This form will be automatically mailed to the Critical Path Project staff for processing.