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Form for representative of an entity or organization
IMPORTANT: Everything with an asterisk must be completed
Please provide the following personal information, writing all your names and lastnames as in your id card.
Dominican Republic ID
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Dominican Republic ID
* Name/s
* Last name
Second last name
* Province
Azua
Baoruco
Barahona
Dajabón
Distrito Nacional
Duarte
El Seibo
Elías Piña
Espaillat
Hato Mayor
Hermanas Mirabal
Independencia
La Altagracia
La Romana
La Vega
María Trinidad Sánchez
Monseñor Nouel
Monte Cristi
Monte Plata
Pedernales
Peravia
Puerto Plata
Samaná
San Cristóbal
San José de Ocoa
San Juan
San Pedro de Macorís
Sanchez Ramírez
Santiago
Santiago Rodríguez
Santo Domingo
Valverde
* Province
* Birthdate
* Gender
Male
Female
* Gender
Difficulty performing certain activities?
* Do you have trouble seeing, even if you wear glasses?
No, no difficulty
Yes, some difficulty
Yes, very difficult
Can't do it at all
* Do you have trouble seeing, even if you wear glasses?
* Do you have trouble hearing, even if you use a hearing aid?
No, no difficulty
Yes, some difficulty
Yes, very difficult
Can't do it at all
* Do you have trouble hearing, even if you use a hearing aid?
* Do you have difficulty remembering or concentrating?
No, no difficulty
Yes, some difficulty
Yes, very difficult
Can't do it at all
* Do you have difficulty remembering or concentrating?
* Email
* Password
The password must have :
at least 6 characters
Confirm password
Form instructions
If you are Dominican, enter your identity card number and click on the magnifying glass.
If your data does not appear automatically, do the following:
Enter your first name(s) and last name(s).
Select your date of birth and gender.
Select the province of residence.
Enter your email and a password.
Please make sure you use a valid email as this will be our primary means of communication with you.
Click the blue button that says “Create User” or “Next.”