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Account Initialization Request Form

Use this form to request a new Regent account initialization email.

If the email address you specify in this form is different from the one we have on file, someone will contact you by phone to verify your identity before sending a new initialization email.

* Denotes a required field.

*First Name:
*Last Name:
*Postal Code :
Nation :
*Birthday: mmddyy
*Email Address:
 * Is this email different from the address we currently have on file? No Yes Unsure
*Phone number:
*Best time to reach you:
Question or Comments: