Personal Information

First name *

Last name *

Phone Number *

Alternate Phone Number 

Email address *

Password * Password must contain
  - A minimum of 7 characters
  - A maximum of 12 characters
  - At least 1 upper case character
  - At least 1 lower case character
  - At least 1 letter
  - At least 1 number
  - At least 1 symbol (?!$*#)
  - No white space

Confirm Password *