SSA-118 Government to Government Services Online Website Registr

Government to Government Services Online Website Registration Form

Complete the following information to obtain access to the eData Website utility. Sponsors should email the completed form to [email protected]. Each new user will receive an email containing the Username and a phone call to provide the password.

Please tab from field to field.

MAIN CONTACT INFORMATION
Name:      
Organization Name:      
Organization ID:      
Street Address (Line 1):      
Street Address (Line 2):      
City:      		State:      		Zip Code:      
Email Address:      
Phone (Include area code):      
ADDITIONAL USER INFORMATION
Enter the name of each new user, including the main contact.
Name	Email Address		Phone		Office Use
     	     		     		     
     	     		     		     
     	     		     		     
     	     		     		     
     	     		     		     
SPONSOR VERIFICATION (For completion by Sponsor only):
Sponsor Name:      			Phone:       (Include area code)
Sponsor Comments:      
Select the utilities the new user(s) will need to access: (select all that apply to every user on this application)
Indicate at least one Trading Partner where the user will send files for DE or SW applications (List all that apply):
Name		City		State
     		     		     
     		     		     
     		     		     
     		     		     

05/07