New Mexico Workforce Connection - Provider Registration

Please enter the following information and click the Save button when you are finished. Also be sure to remember your username and password. You will need them to access this system again.

For help click the information icon.

indicates required fields.

User Name:

Enter Unique User Name (3 - 20 Characters, letters or numbers)

Password:

Enter Password (8 - 20 characters, and must include at least one uppercase letter, one lowercase letter, one number and one special character. Allowable characters are # @ $ % ^ . ! * _ +). Allowable characters are ! @ # $ % ^ * . _

Confirm Password:

Security Question

Security QuestionRequired Field

Security Question Response:

Security Question Response: Hint to help if you have forgotten your password.

Federal Employer ID

Federal Employer ID No: or Social Security Number:

Federal Employer ID No: or Social Security Number: Do not enter dashes. Example 999001111

Type of Identification:

Social Security Number

Federal Employer Identification Number

Institution Identification

Institution Name:

Institution Code/BPA# (if you are a current provider):

Institution Primary Location

Address 1:

Address 2:

City:

State:

State:Required Field

Zip:

[Find Zip Code]

Contact Information

Salutation:

Title:

First name:

Middle Initial:

Last Name - (include suffix e.g. Jr, Sr, PhD, etc):

Contact Phone Number:

-Contact number prefix -Contact number suffix Ext.Contact number extension

Cell Phone

-Cell Phone Prefix - Cell Phone Suffix

Contact Fax Phone Number

-Fax number prefix - Fax number suffix

Email Address:

Preferred Notification Method

Institution URL:

Institution URL: Enter URL e.g.(http://www.companywebsite.com)

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