Registration Application

Please review the Requirements page before starting this Registration form.

Your Registration Application will be reviewed by our staff for approval and, once approved, you will receive an email confirming your registration with a link to complete the facility registration process. If you do not receive an e-mail link or response within 72 hours of submitting your registration, please contact 1-916-242-8287.

Facility Name & Location

Facility Name *

Operation/Line Name *

Address *

City *

State *

Zip *

Contact Information

Contact Person *

Position *

Email *

Password *

Main Number * - - ext

Website *

Payment Information

Card Holder’s
First Name *

Card Holder’s
Last Name *

Card Type *

Card Number *

Expiration Date *

Billing Zip Code *

Security Code *

I authorize RCI to charge the amount of $400.00 to my Credit Card