Application for HILIS Registration

Welcome to HMDS

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Application for HILIS Registration

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Please enter your details below. All fields are required.

[% END %] [% IF errs.error_other_role || errs.error_other_source %]

please enter an alternative role if selecting 'other'
please enter an alternative location if selecting 'other'

[% END %] [% IF msg %]

Sorry, there is a problem with the mail server and your message was not sent. Your details have been preserved in the form below, please try again shortly. The error message was: "[% msg %]". Please copy this message to HMDS admin if the error persists. Apologies for the inconvenience.

[% ELSIF send_success %]

Your registration details have been submitted. You should receive an e-mail copy within 24 hours at [% vars.email %], but if not please contact HMDS admin.

[% END %]

First Name:	[% errs.error_first_name %]
Last Name:	[% errs.error_last_name %]
Location:	[% errs.error_location %]
Department:	[% errs.error_dept %]
Role:	[% errs.error_role %]
Departmental address:	[% errs.error_contact %]
Telephone:	[% errs.error_tel %]
E-mail:	[% errs.error_email %]	re-type e-mail for validation: [% errs.error_email2 %]

[% UNLESS send_success # already submitted %]

[% END %]