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Create a "My Encore" Account

Completing this form will create an account for you to use when on our customer site. The profile information, while optional, will be used to auto-complete certain fields on various forms saving you time in providing contact and other information. It can be modified by you if this information changes at a later time.

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Profile Information (all fields in this section are optional)
   First Name:
   Last Name:
   Company Name:
   Main Business Phone:     
   Direct Line:     
   Extension: x-
   Fax Number:     
   Business Address:
   City:
   State:
   Zip:

   This selection is used to help customize your profile data properly and is required
  
  Associated with Encore as a:

  

Please note selecting "other" may cause your profile data not to display on referral forms

Account Information (all fields in this section are required)
       
   Password:     
  *Passwords must be 7 characters and / or numbers in length and contain at least 1 number and 1 special character such as !,@, or #.
   Confirm Password:
       
   
If you forget your password you can use the security question and answer to have it emailed to you
       
  Type in a question for the site to ask you in case you forget your password.
       
  This is the answer you will need to provide to have the site email the password to you.

   
      
 
   
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