Organization Registration

Please fill out form with necessary information and click the submit button below.

Organization/Group Name	ASI Moses Residence
Primary Phone	218-340-6490
Primary Email	sspence@accessiblespace.org
Address	220 17th Street NW
Address Ln 2
City	Grand Rapids
State	MN
Zip	55744

Individual Contact Information

First Name

Last Name

Cell Phone (Primary)

Phone (Alternate)

Department

Password (Minimum of 6 Characters)

Password (verify)

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