Victorville - Safe City^™ 
C.O.I.N. Access Registration
C.O.I.N. Participants Only
* required

APPLICANT INFORMATION First Name:* Last Name:* Position/Title (if applicable) Company /Organization Name: CONTACT INFORMATION Phone: (include area code)* TEXT MESSAGE ALERTS Mobile Phone: (include area code, no dashes) Mobile Provider: Select your mobile provider...AT&T WirelessCingular WirelessNextelSprint PCST-MobileVerizon WirelessVirgin MobileAlltelQwest Mobile Email Address Fax: (include area code) E-mail:*		Address:* Address 2: City:* State: (ie: CA)*    Zip code:* MEMBER TYPE BUSINESS/ORGANIZATION Banks & Credit Union/Securities   Movie Theatres/Entertainment Community Interest Groups   Pharmacy Convenience Store   Property Management Daycare   Public Health EMS Fire   Religious Organizations Energy/Utility Provider   Restaurant K-12 Schools/Colleges/ Universities/Trade Schools   Retail Store Other    If Other, specify below
BRIEFLY DESCRIBE YOUR ORGANIZATION