User Details ***Please note password should have minimum length of 6

	User Name*			Password*			Confirm Password*

Personal Details ***For easier date input please start by selecting year, month, then date***

	First Name *			Middle Name
	Last Name*
	Physical Challenge status*	No Yes		Date of Birth *
	Gender*	<None> Male Female		Marital Status*	<None> Single Married Divorced
	County of Origin*	<None> Baringo Bomet Bungoma Busia Elgeyo-Marakwet Embu Garrissa Homa Bay Isiolo Kajiado Kakamega Kericho Kiambu Kilifi Kirinyaga Kisii Kisumu Kitui Kwale Laikipia Lamu Machakos Makueni Mandera Marsabit Meru Migori Mombasa Muranga Nairobi Nakuru Nandi Narok Nyamira Nyandarua Nyeri Samburu Siaya Taita Taveta Tana River Tharaka Nithi Trans-Nzoia Turkana Uasin Gishu Vihiga Wajir West Pokot		Ethnicity*	<None> Arab Embu Gabra Kalenjin Kamba Kikuyu Kisii Kuria Luhya Luo Masaai Meru Miji-Kenda Njemps Nubi Orma Pokomo Rendile Samburu Somali Suba Swahili Taita Taveta Teso Turkana Others

Security Questions ***Please Note Answers Are Case Sensitive***

	Security question 1 *	Select one... What is your mother First name? Which city or town were you born? What is the name of the primary school you attended? What is the name of the secondary school you attended?		Answer 1*
	Security question 2 *	Select one... What is your mother First name? Which city or town were you born? What is the name of the primary school you attended? What is the name of the secondary school you attended?		Answer 2*
	Security question 3 *	Select one... What is your mother First name? Which city or town were you born? What is the name of the primary school you attended? What is the name of the secondary school you attended?		Answer 3*

Contacts

	Phone Number*			Email Address*

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