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User Registration

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Type of Application

New Application	You've never had an online account with TTB
Reactivate an Inactive Account	In the past, you had an online account with TTB that has been inactivated

Personal Information


*	First Name: M. I.: * Last Name: Suffix:

Employer:

* Title: Label Rep. ID:

Phone Number:

Fax Number:

Address Format:

Street:

City:

State:

Zip:

Country:

Region:

Province:

Foreign Postal Code:

Business E-mail Addresses

Up to three e-mail addresses may be provided. COLAs Online and Formulas Online will correspond with the Primary e-mail address.

Set as Primary			E-mail Address

*
*
*

Authentication Questions

Select three questions and provide answers. These answers will enable you to create your initial password, and will be used for authentication should you ever forget your password.

	Question	Answer

* 1:
* 2:
* 3:

We collect this information to verify your compliance with Federal laws and regulations that TTB administers. The information collected on this form must be considered confidential tax information under 26 U.S.C. 6103, and must not be disclosed to any unauthorized party under 26 U.S.C. 7213.