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Use this form to request an account with the University of Arkansas - Distance Diagnostics System. All fields labeled in RED or noted with an "*" are REQUIRED. The Username should not contain any spaces. Your password cannot be the same as your username and your password must be at least eight (8) characters in length. *Username: *First Name: *Last Name: *County/Location: Select One Arkansas Ashley Baxter Benton Boone Bradley Calhoun Carroll Chicot Clark Clay Cleburne Cleveland Columbia Conway Craighead Crawford Crittenden Cross Dallas Desha Drew Faulkner Franklin Fulton Garland Grant Greene Hempstead Hot Spring Howard Independence Izard Jackson Jefferson Johnson Lafayette Lawrence Lee Lincoln Little River Logan Lonoke Madison Marion Miller Mississippi Monroe Montgomery Nevada Newton Ouachita Perry Phillips Pike Poinsett Polk Pope Prairie Pulaski Randolph Saline Scott Searcy Sebastian Sevier Sharp St. Francis Stone Union Van Buren Washington White Woodruff Yell NA Out of State *Address1: Address2: *City: *State/Territory: Select One ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING *Mail Code: *Country: *E-mail Address: *Phone: (format "(999) 999-9999") Fax: Affiliation: *Password: *Verify Password:

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