Knowledge Ontario Registration

	Items marked with a * are required. NOTE: Hospital members do not have to fill out this form. A spreadsheet with the required information is being complied by Sophie Regalado.
	Main Contact
Name *
Title
Institution *
Address1 *
Address2
City *
Postal Code *
E-mail *
Telephone *
Should this person be set up to receive monthly stats reports?	Yes No
	IT / Technical Contact
Name
Title
Address1	Leave blank if not
Address2	applicable or the
City	same as main contact.
Postal Code
E-mail
Telephone
	Authentication Information
IP addresses	Valid IP ranges will have the following format: 199.199.199.55-255 or 199.199.55-75.* or 199.199.199.*

Referring URLs
Password[s] or Bar-coded ID.	Passwords are case sensitive. For the bar-coded id, we need the length of the barcode and the prefix. e.g. 14 characters starting with "00025"

Questions or Comments