Logout
Profile Registration
Return to MyEsquimalt
Complete this form to register a MyEsquimalt profile. All boxes with a red asterisk must be filled in.
Applicant Information
First Name
First Name is required
Last Name
Last Name is required
Email Address
Email Address is required
Please enter email in the format: myemail@example.com
Phone
Phone Number is required
Please enter a 10 digit phone number
Address Information
Business Name
Password Information
Password must be 6 characters and contain at least one number and one special character.
Password
Password is required
Confirm Password
Confirm Password is required
Security Question
Select...
In what city did you meet your spouse/significant other?
In what city does your nearest sibling live?
In what city or town did your mother and father meet?
In what city or town was your first job?
What is the first name of the boy or girl that you first kissed?
What is the middle name of your oldest child?
What is the name of a college you applied to but didn't attend?
What is the name of the place your wedding reception was held?
What is the name of your favourite childhood friend?
What is your maternal grandmother's maiden name?
What is your oldest brother's birthday month and year? (e.g. January 1900)
What is your oldest cousin's first and last name?
What is your oldest sibling's birthday month and year? (e. g. January 1900)
What is your oldest sibling's middle name?
What school did you attend for sixth grade?
What street did you live on in third grade?
What was the last name of your third grade teacher?
What was the name of your first stuffed animal?
What was your childhood nickname?
What was your childhood phone number including area code? (e.g. 000-000-000
Where were you when you had your first kiss?
Question is required
Security Answer
Answer is required
Captcha invalid.
Please re-type