Online Application Form

Name
Organization
Address
City
State	Zip
Country
Phone

Please specify a user name which you will use on our system. The username must consist of 2-8 lower case letters and not contain any punctuation.  

Please specify a password which you will use to gain access to our system.

The password MUST be constructed to meet the following requirements:

• The password must have eight characters.
• The password must contain at least two alphabetic characters, at least two numeric characters, and at least two special characters (punctuation).
• The password must not resemble the user's login name or any reverse or circular shift of that login name.
• The password must not contain the user's initials.
• The characters of the password must not be able to be re-arranged to form a name, place, thing, or any word that can be found in the dictionary.

The password supplied below must meet each requirement stated above—no exceptions.

Password:
Password (enter again for verification):

DESCRIBE YOURSELF (Optional)

Are you one or more of the following:
Person with HIV/AIDS
Health Care Professional
AIDS Service provider
AIDS activist
AIDS researcher
Fuller Information Exchange
None

Race: Please specify African descent Latino/Latina Caucasian Asian-Pacific Islander American Indian Multi-Racial Other

What is your current age? Under 18 18-30 31-40 41-50 51-60 61-70 71-80 Over 80

Please click on the submit button one time only. This form will be automatically mailed to the Critical Path Project staff for processing.