Information for Amputees Resource kit Generation systems-application form

Information For Amputees Resource Kit Generation System - Application for User account

Small leg
Register your details here for the REHABTech Resource Kit Generation System

Please read these additional notes before you apply to access the system.

Please review the Help section first! Instructions for using the system and its functionality are in the help section at
http://rehabtech.eng.monash.edu.au/information/help.asp
We ask you to choose your own ID and password. They will be case sensitive and confirmed by us in a return email.
All fields are mandatory.
The system enables you to generate your own "purpose-built" documents. You are able to decide how you want your contact information to appear at the end of these documents by filling in the category below marked Contact information for documents.
The category marked Additional reference information is for our records. This information will not be used for any other purpose.

Contact details field: Add your information Explanation of field

Choose Your ID -
Mandatory field
This will be confirmed by REHABTech after you submit your application.
The ID will be case sensitive. Do NOT use spaces and limit to 6 characters.

Choose Your Password-
Mandatory field
This will be confirmed by REHABTech after you submit your application.
The Password will be case sensitive. Do NOT use spaces.

Title (Mr, Ms, Dr etc)

Family Name Mandatory field

Given Name Mandatory field

Email address Mandatory field

* Postcode (zipcode) Mandatory field

Additional reference information:

Occupation Mandatory field
This information appears at the end of any document you create.

Organisation name Mandatory field
This information appears at the end of any document you create.

Organisation address Mandatory field
This information appears at the end of any document you create.

Work Telephone Mandatory field
This information appears at the end of any document you create.

Work Fax Mandatory field
This information appears at the end of any document you create.

Additional information for documents:

e.g.
website address
extra telephone numbers
Mandatory field
This information appears at the end of any document you create.