EOLSS ON-LINE REGISTRATION FOR
INDIVIDUALS (GENERAL)
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1. CONTACT INFORMATION
(Note: Type NA, if the field not applicable)
Title
*
First Name
*
Last Name
*
Organisation/Ins
*
Email Address
Confirm Email Address
*
Are you an author of EOLSS
*
If yes, please give specific contribution title
*
Address
City
Prov/State
Postal code
Country
*
Phone Number
*
Fax Number
How did you find about EOLSS
*
If "Other" please specify:
*
Preferred User Name
*
Username must be between 8-12 characters with no blank spaces.
Preference Code
(Please enter your Preference
Code to take advantage of your special offer.
If you do not have a Preference Code, leave this field blank.)
2. PROFILE (Activity)
Please select the one response below which best describes your
Activity:
*
If "Other" please specify
Primary Job Function
If
"Other" please specify
From the list of subject categories below
please select the ONE which best describes your area of work or study
*
3. PAYMENT*
Coupon Code
Select Plan
Amount
$25
Mode Of Payment
Credit Card Type
|
(Credit card number must not contain blank spaces or hyphens)
Cardholder Name
*
Credit Card No
*
Card Identification No
Expiry Month
Expiry Year
Draft No
*
IssueDate(mm/dd/yyyy)
mm/dd/yyyy
IssueBank
Thank you for your order
For your convenience, subscription will be automatically renewed
until you request cancellation.
[For cancellation, send an email to  ]
Alternatively:
downloadable Registration Form in
PDF or Word is
available.
For Further Information contact:
Drafts must be in EUROS/UK£/US$. International money orders are
also accepted.
Please read the following carefully:
I understand that completion of this form is a binding agreement
and I offer my personal e-mail address in lieu of a signature:
Enter the Code Shown above
*
(Note: If you cannot read the numbers in the above
image, reload the page to generate a new one.)
OR Print and Email with your signature to  .
NOTE:
Please use an active email address when registering to EOLSS.
An activation email will be sent to the email address associated with your
account to provide you access to the service.
Please also
ensure that any email spam filters are properly configured to ensure that you
recieve the activation email from EOLSS.
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