Create a Provider Account

Provider Name:
Provider Business:
This is an organizational account
Email (username):	(E-mail)
Password:
Re-type Password:
Contact First Name:
Contact Last Name:
Address:
Address2:
City:
State:	-:State:- AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Phone:
Fax:
	Type the characters you see in the picture below.
On the next screen you will be prompted to login and offer a service.

For The Seventh Generation is a program of the Detroit Metropolitan Bar Association Foundation in cooperation with
the 3rd Judicial Circuit of Michigan and the Michigan Department of Human Services. The Detroit Metropolitan Bar
Association Foundation is a 501(c)(3) organization. Donations of cash and goods are tax deductible as provided by law.

1356 Penobscot Building 645 Griswold Street Detroit, MI 48226-4220 Phone: (313) 961-6120 ext. 206
Fax: (313) 965-0842 Email: 7thGen@detroitlawyer.org Website: www.fortheseventhgeneration.org