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Sign Up for a Second Email Address

Please fill out the following form to request your 2nd free e-mail address.  A Mid-Rivers Customer Services Representative will contact you after you submit this form to confirm your request and to complete the activation of your new e-mail address.

Please provide us with the following information:

Username (3-10 letters, all lower case):

You will also need a password. A Customer Service Representative will contact you personally for this information.

First Name:

Last Name:

Company / Organization:

Street Address:

Address (continued):



Zip Code:

Home Phone:

Work Phone:

Member Number:

Current Email Address:

To verify your submission please type in the text you see above:

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