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Illinois Assistive Technology Program

Independent Living through Technology

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Basic Information ALL FIELDS REQUIRED

First Name: *   Middle Initial: * (if no middle initial enter "N/A")   Last Name: *   Generation: * Select JR SR II III IV V N/A (if no generation select "N/A")   Email Address: *

User Credentials

User Name: * (between 5 and 25 alphanumeric characters)   Password: * (between 6 and 15 characters and contain an uppercase letter, lowercase letter and a number)   Confirm Password: *