Non-Illinois Account Creation

Account Information

Email/Username *	Please provide your email address. Please enter the correct email format. Example: example@example.com
Password *	Please enter a password. Minimum length for password is 8 characters.
Confirm Password *	Please re-enter the password.

Demographic Information

First Name *	This field is required
Middle Name
Last Name *	This field is required
Preferred Name
Alternate Email	Please enter the correct email format. Example: example@example.com
Home Address *	This field is required
City *	This field is required
State/Province *	This field is required
Zip *	This field is required
Primary Phone *	This field is required
Gender *	Please Select Male Female Unknown Please select a gender.
Ethnicity *	African-American Asian Hispanic Native American/Alaskan Native Hawaiian/Pac Isl White Multi-Race International

Employment Information

Employer *	This field is required
Department *	This field is required
Position Title *	This field is required
Work Address *	This field is required
Work City *	This field is required
Work State/Province *	This field is required
Work Zip *	This field is required
Work Phone
Work Country

Academic Information

Bachelor's Degree
University Name *	This field is required
Academic College *	This field is required
Major *	This field is required
Second Major (if any)
Year of Graduation *	This field is required

---

Master's Degree (if any)
University Name
Academic College
Major
Year of Graduation

---

PhD Degree (if any)
University Name
Academic College
Major
Year of Graduation

---