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External User Registration Form
Required Field
*
Title:
*
First Name:
*
Middle Name:
Last Name:
*
How do you want to receive your Password?
(not required for Customer Online - Coal)
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Mobile Number:
*
Your password will be sent to this number
Work Email Address:
*
Secret Question:
*
Secret Question examples - Mother's maiden name, Name of family pet. Do not use company specific questions.
Secret Question Answer:
*
Job Title:
*
Company:
*
Mine/Port Access Required:
Do you require access to a mine or port? If so which ones?
What application are you requesting access to?
*
Select an Application
Do you require additional application access?
*
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Additional Applications:
Aurizon Contact Person:
*
Aurizon Contract No (Ac. XXXX):
*
Aurizon Contract Title:
*
SharePoint Site:
Customer Account Number:
Manager's Name:
Manager's Position:
Manager's Phone:
Manager's Email:
Roles:
Practice:
Comments/Reason for Access: (for Sharepoint access, please enter site description and the name of your Aurizon Contact)
*
Have you read and accepted
Aurizon IT's Terms and Conditions
URL:
Click here to configure hyperlink
Display:
Click here to specify hyperlink
Yes
Please enter your Signature
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