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Last Name: *

Address: *

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Cell Phone: * Format (no spaces or dashes): xxxxxxxxxx Select Your Cell Phone Provider: -Select One- ACS Wireless AIO Wireless Alaska Digital Alltel Alltel MMS Ameritech AT&T AT&T MMS Bell Mobility Bell Mobility Canada Boost Cellcom CellularOne CellularOne West Cellular South Centennial Wireless Cincinnati Bell Wireless Consumer Cellular Credo Mobile Cricket Edge Wireless Fido Canada FirstNet At&T FirstNet (Verizon) Gmail Google Project Fi Inland Cellular Koodo Canada Metro PCS MobileOne MTA Telecom MTS Mobility Nex-Tech Nextel Ntelos Rogers/Tbaytel Mobility PCS Wireless Qualcomm Qwest Republic Wireless Sasktel Mobility Simple Mobile Sprint MMS Sprint PCS StraightTalk Tbaytel Mobility/Rodgers Telus Mobility Thumb Cellular Ting T-Mobile T-Mobile Sidekick Total Wireless Tracfone Direct Union Wireless US Cellular Viaero Wireless Verizon Wireless Verizon Wireless MMS Virgin Mobile Virgin Mobile Canada Wind Mobile Xfinity Mobile * Send Me Text Message Alerts: YES NO

E-Mail Address: * Do not use the following email domains: midwayfire.com gmail.com yahoo.com hotmail.com Allow other members to view my email address

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Member # : *

Local#4192 : --Select One-- Midway Professional Firefighters

Choose Username: * (DO NOT use spaces)

Choose Password: *

Password Strength: Weak Strong passwords contain 3 of the following items and at least 6 characters: - Uppercase Letters - Lowercase Letters - Numbers - Symbols

Do you need email @iafflocal4192.org? Yes No (Select Yes to have an email address created for you @iafflocal4192.org using the username and password you specified above.)

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