iChain User Self-Registration (GET Method)

Illinois Department of Public Health

Web Portal User Registration

Please enter the following information:

Username (ex: bsmith):^*
First Name:^*
Last Name:^*
Password:^*
Confirm Password:^*
Title:^*
Organization:^*
Department:^*
Work address:^*
City:^*
State:^*
Zip code:^*
E-mail:
Work phone #:^*
Cell phone #:
Pager #:
Fax #:
Supervisor's name:
Instructions:

I agree to the Web Portal User Account Agreement:

^* required.

Instructions:

For administrative purposes, the Username should be composed of user's first initial and last name, up to a total of eight characters. Username may be modified to include a number in the last position to avoid duplicates (i.e. bsmith, bsmith2).

Password should be no less than eight characters consisting a combination of letters and numbers.

Web Portal User Account Agreement: users must read and agree to this user account agreement in order to register for an account.

Web Portal Registration Form: if you need a copy of the registration form, click on this link.

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