Basic Folder Information

Registration

Self Registration

To obtain an account in the eBridge system, complete this registration form. When you select "Register", the information you provide will be sent to the Help Desk. If you are an MCW employee, the Help Desk will create your account by the end of the next business day. Otherwise, verifications need to be made and account creation can take longer. Once your account is created, you will receive an email with your login information.

What is your full, legal name? (No nicknames or abbreviated names. If you do not have a Middle Name, then enter n/a.)

	Prefix:
*	First:
*	Middle:
*	Last:
	Suffix:
	Degrees:
*	Job Title:

*	Email Address:
*	Business Phone:
	CITI Member ID:

Do you need to login to eBridge? Yes No Clear

* Mobile Phone:

* What do you consider to be your primary organization?

	Children's Wisconsin
	Froedtert Hospital
	Marquette University
	Medical College of Wisconsin
	Milwaukee School of Engineering
	University of Wisconsin - Milwaukee
	Versiti, Inc.
	Clement J. Zablocki Veterans Affairs Medical Center
	Other
	Clear

* Which of the following best describes your role at your primary organization?

	Faculty (including Adjunct Faculty)
	Staff (employee or volunteer)
	Student
	Resident or Fellow
	Clear

* Have you previously had an eBridge account? (maybe as a previous employee or student, or with a different name, maiden name, or email address)

* Are you requesting this account for someone else?:
Yes No Clear


* Required

Basic Folder Information

Registration

Self Registration

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