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Use this form to request an account with the Alabama Cooperative Extension System Distance Diagnostics through Digital Imaging system. All fields labeled in RED or noted with an "*" are REQUIRED. The Username should not contain any spaces. *Username: *First Name: *Last Name: *County: Autauga Baldwin Barbour Bibb Blount Bullock Butler Calhoun Chambers Cherokee Chilton Choctaw Clarke Clay Cleburne Coffee Colbert Conecuh Coosa Covington Crenshaw Cullman Dale Dallas DeKalb Elmore Escambia Etowah Fayette Franklin Geneva Greene Hale Henry Houston Jackson Jefferson Lamar Lauderdale Lawrence Lee Limestone Lowndes Macon Madison Marengo Marion Marshall Mobile Monroe Montgomery Morgan Perry Pickens Pike Randolph Russell Shelby St Clair Sumter Talladega Tallapoosa Tuscaloosa Walker Washington Wilcox Winston Select One *Address1: Address2: *City: *State: *Zip: *E-mail Address: *Phone: (format "(999) 999-9999") Fax: *Password: *Verify Password:

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