SURIPAK Registration Form

Fill in Registration information below.
Items with asterisk '*' indicate required information.

Registration Information

Tue Apr 23 09:40:01 EDT 2024

*Type of Account

Personal

Business

Business Name:

*First Name:

*Last Name:

*Home Address:

*City:

*Country:

*Home Phone:

Cell:-

*Work Phone:

Ext:-

*Email Address:

*ID Number:

*ID Type:

*Date of Birth:

How did you hear about us?

*Password:

Password must be 6 to 12 characters and/or numbers.

*Password Hint:

If you forget your password, enter a hint that will remind you.

*Pickup Location:

Authorised to sign for SURIPAK deliveries

If you are not available when the package is delivered, list
up to 2 people authorised to sign for the package on your behalf.
Leave blank if you do not want anyone else to sign on your behalf.
You can add people later.