Banner Student Authorization Request Form


Please complete the top of the form online then print the form to obtain the necessary signatures. Return to: Stacey Flowers, Flanagan Campus for LifeLong Learning Dennis Grassini, Knight Campus for Business Division Renee Gaboury, Flanagan Campus for Student Affairs and all other departments
Date:
First, MI, Last Name:	Title*:
		*Please indicate if you work through a Temp Agency
Department:	Campus:

Phone Ext:	Email:				@ccri.edu

Employee Role:

Faculty Staff Student Help			Intern/ Volunteer Date: Begin End
Account Type:
New Terminated Change Reason for Change:

Agreement: I have read, understood, and agree to comply with FERPA regulations, the CCRI Data Security Policy and the CCRI Policy on the Responsible use of Information Technology; I understand that I am responsible for any computing activity carried out using this account. Access to Banner Student will be activated upon completion of all training.

Applicant’s Signature						Date

Supervisor’s Signature						Date

For Office Use Only
Module:				User Role No.:
Access to: Test Production
Data Access Office Signature:						Date:
IT Dept. Completion Date and Initials: