Balloteer Online Elections and Voting - Balloteer Account Registration

You may use the following form to register for a Balloteer account. Please enter information in all of the required fields, which are marked with a * character. You will have a chance to review your entered information in Step 2 prior to final submission.

Account Contact Information

*First Name:
*Last Name:
Title:

Company/Organization:
*Address 1:
Address 2:
*City:
State/Canadian Province:
International Province:
Zip/Postal Code:
*Country:

*Phone:
Fax:

*E-mail Address:
*Required Fields

Select a Password
Use the input fields below to assign yourself a password. Your user name will be your e-mail address. The password must be unique, and should be at least 6 characters long and no more than 20 characters long. Password are case-sensitive and must only be comprised of the letters "a" to "z" and the numbers "0" to "9". All passwords must contain at least one numeric digit for security purposes. Users are strongly discouraged from using any word that would appear in a dictionary as their user name or password.
*Password:
*Confirm Password:

Balloteer Discount and Special Access Code
If you have been supplied a Discount Code or Special Access Code by Telusys for Balloteer services, please enter the code here. Do not enter credit card payment information when using a special access code for a demo or complimentary account.
Special Access Code:

Payment Information

Enter your payment information below. Balloteer registration requires payment via credit card. The billing contact information below should be the credit card statement address of the card holder.

Yes, my billing address is the same as the contact address above.

*First Name:

*Last Name:

Company:

*Billing Address1:

Address2:

*City:

State Zip Code

*Country:

*Card Type:

*Card Number:

*Card Security Code:

(3 or 4 Digit Security Code from Back of Card)

*Exp. Date:

Month Year

Registration Selections:
*Election Title:
	*Balloteer Account Registration - One Election 5,000 Ballots: $99.95

	*Add Additional Ballots:

	*Add Self-Managed E-mail Services:
BALLOTEER MANAGED ELECTION SERVICES
	*Add Managed E-mail Notifications Services to My Election: $350.00 1) Send Election Vote Link; 2) First Reminder to Vote; 3) Second Reminder to Vote
	*I wish to have Balloteer Staff Fully Manage My Election: $750.00 Add candidates, bios, photos, and send 3 election e-mail notifications to voters: 1) Send Election Vote Link; 2) First Reminder to Vote; 3) Second Reminder to Vote

*Balloteer registration and usage fees are non-refundable. By clicking the "Register for Balloteer" button below you are accepting these charges on the credit card that you have supplied. Balloteer Fully Managed election pricing and E-mail Notification service pricing is for a basic 5,000 ballot election and is subject to Balloteer terms, conditions, and restrictions.

Digital Signature
By typing your name below in the signature box, the client acknowledges that they have read and understand the terms and conditions of this agreement and agree to be bound by the Terms and Conditions of this agreement.
I have read the Terms and Conditions of this agreement and accept them in their entirety. I understand that the Terms and Conditions of service are subject to change with or without notification and I will consult the Balloteer.com Web site regarding updates.
Signature: