Bally Technologies, Inc.

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New User Request Form

First Name: * (Nombre)
Last Name: * (Apellido)
Title: (Titulo)
Company: * (Compa��a)
Street Address: (Direccion)
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City: (Ciudad)
State/Province: (Estado/Provincia)
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Country: * (Pais)
Business Phone: * (Telefono Comercial) (Numbers Only: No Spaces)	EXT.
Business Fax: (Fax Comercial) (Numbers Only: No Spaces)
Business Email: *
Select a Username: * (Nombre del Usuario) (Spaces not allowed)
Select a password: * (Contrasena) (Spaces not allowed)	Min 7 chars, (min 1 upper Alpha, & 1 Number required.) A value is required. The minimum number of characters not met. The maximum number of characters exceeded. The password strength condition not met. User defined condition not met.
Confirm password: * (Confirme Contrasena) (Spaces not allowed)	Min 7 chars, (min 1 upper Alpha, & 1 Number required.) A value is required. The minimum number of characters not met. The maximum number of characters exceeded. The password strength condition not met. User defined condition not met.
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Please allow 48 hours, an email confirming your User ID and Password will be sent to you.