Campus Domain Account Application Form

*Please print the form, complete it and return it to the Department of Information Technology, attn: Help Desk*

Last Name: __________________ First Name: ________________________________ Middle Initial:_____
(Please Type or Print Clearly)

CCRI ID# * or MyCCRI Username ____________________________________________ Date:____________

*Your CCRI ID# is the 8-digit number below your name on your Faculty/Staff or Student ID.

Title:_________________________________________________ Phone: __________________________

Department:______________________________________ Campus: ______________________________

Please check one of the following Primary Use (Please check all that apply)
Faculty - full time ☑   Domain
Adjunct Faculty (part time) Access to Dept. Share Drive
Staff Other
Student**  
Lecturer  

**Student accounts are terminated at the end of the current semester.

Are you temporary: yes   no        If yes termination date:________________________________

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OCS (Office Communicator Server)
Type of Service:
Unrestricted Restricted (Access to calling) In-state Long Distance

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Agreement: I have read, understand, and agree to comply with 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.

Routing:

Applicant's Signature: ______________________________________________ Date: _____________

Department Head's Signature:________________________________________ Date:_____________

IT Use Only: Date Acct. Created: _______________  Acct. Termination Date: __________ Initialed:_________

Please print the form, complete it and return it to the Help Desk