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Account Request
Please complete the form below to receive a Certificate Administrator's login and password on BollingerLAX.com.

Your First Name: 


Your Last Name: 


Phone: (ex: 555-555-5555)


Extension: 
 Organization Name: 


Address:
 

Address 2:
 

City:
 

State:
 


Zip Code:
 

Select Your User name:


Password:


Password Confirmation: 


Email Address:


Email Address Confirmation:


I certify that the team or league for whom I am requesting this certificate mandates 100% membership in US Lacrosse, and that I have verified our team/league's roster and all participants are current members of US Lacrosse.

I certify that this is true and I understand that a roster will be required in the event the event of a liability claim in order to confirm membership. I understand that liability claims will only be covered if the team carries 100% membership in US Lacrosse.



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