Please complete the top 2 sections of this form and then print the form to obtain necessary signatures. Return to: Business Office – 3^rd Floor Knight Campus

Date:  

First, MI, Last Name:

Title:

Department:

Campus:

Phone Ext:

Email:

@ccri.edu

Employee Role:

Faculty  Staff   Student   Lecturer

Account Type:

New       Change

Required Security Classes:

Entry Level  Approval Level

Agreement: I have read, understood, 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

Supervisor’s Signature

Date

Business Office Use Only

User Role:

Access to:     Test Production

Data Access Office Signature:

Date:

IT Dept. Completion Date and Initials: