Rural Municipality of Hanover

Step 1. Create Billing Contact

Step 2. Activate Account

Step 3. Account Activated

Contact Information Note: Red text indicates required fields.

Billing First Name:

Billing Last Name:

Address 1:

Address 2:

Country:

Prov/State:

City:

Postal/Zip Code:

Phone 1:

Phone 2:

Email:

Alternate Email:

Client #:

Account Information

Username:
		* We suggest your email address (Min Characters: 5)

Password:

Re-Type Password:

Password Strength

Note: For the best Password Strength rating include:

Extra Information

Birthdate:

Emerg. Contact:

Emerg. #:

Permission To Take Photo(s) Granted

Medical Information

List any medication presently taken:

Do you have any of the following conditions or requirements?:

Allergies:		Yes		No	Epi-pen Required:		Yes		No
Other Medical Conditions:		Yes		No

Please explain:

Security Check

Captcha Verification