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Campus Domain Account Application Form
*Please print the form, complete it and return it to the Department of Information Technology, attn: Help Desk*
First Name: __________________ Middle Initial:_____ Last Name:
________________________________
(Please Type or Print Clearly)
Title:_____________________________________________________________________________________
Department:______________________________________ Campus: _________________________________
CCRI ID# * or Pipeline Username ____________________________________________
(if you do not have a CCRI ID# or Pipeline username, please call the
Help Desk at 401-825-1112)
*Your CCRI ID# is the 8-digit number below your name on your Faculty/Staff or Student ID.
Phone: ___________________________________ Date:___________________________
Please check one of the following:
| Faculty:________ | Staff:________ | Student**:________ | Lecturer:_______ |
**Student accounts are terminated at the end of the current semester.
Please check the type of request:
| Campus Domain Account: ________ | Change: _______ | Renewal: ________ |
Primary Use (Please check all that apply):
| Faculty Web: ____ | Domain: ____ | Access to Dept. Share Drive: ____ | Guest E-mail: ____ |
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.
Applicant's Signature: ______________________________________________ Date: _____________
Department Head's Signature:________________________________________ Date:_____________
Please print the form, complete it and return it to the Department of Information Technology, attn: Help Desk
