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Request a Web User Account

Request a Web User Account

Please complete and send this form in order to request a User Account (username and password) that will allow you to access the members-only areas of Selected's website. Headquarters also will use the information you provide to update your listing in the membership database.

Your request must be manually processed to confirm your affiliation with Selected Independent Funeral Homes, so there may be some delay before you receive you Log In information. If you have any questions about the status of your request, please contact Headquarters at 1-800-323-4219 or info@selectedfuneralhomes.org.

(*) denotes required information. Thank you.



First Name (*)

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Middle Initial

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Last Name (*)

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Suffix (Jr., III, Sr., etc.)

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Title

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Firm Name (*)

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Firm City (*)

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Firm State/Province (*)

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Your Email (*)

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Work Phone

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Home Phone

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Cell Phone

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Birth Date

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Spouse's Name

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Would you like to receive messages from Selected's Forum in your inbox?

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Additional information or comments

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