Please complete this form to create your user account. The information you provide will be used to create your account and to connect you with the correct business or to create a new business, if one does not exist. You will receive credentials or a request for additional information in 1-3 business days at the email address provided. You may email MyEHS@smcgov.org with any questions or if you do not receive a response after 3 days.

First Name *

Last Name *

Employer *

Email * Please enter a valid email

Phone *

Mailing Street, including suite, unit, etc. *

Mailing City *

Mailing State *

Zip Code *

Your relationship to the business to which you are requesting access *

Owner Billing Contact Site Contact Other Employee Contractor Consultant

Username * Please enter a username in the correct format, e.g. example@test.com Username is available Username is not available. Try a different username or choose one from the options below. Please check username availability before submitting the form

Facility Information

BLA/IA number(If known)

Name *

Address *

City *

Zip Code *

Type of Facility

CERS ID (if known)

Business Owner Information

Business Name for which you are requesting access *

Phone Number *

Email Please enter a valid email

Mailing Street, including suite, unit, etc. *

Mailing City *

Mailing State *

Mailing Zip Code *

Other Information

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