*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*:

Department:

Campus:

Phone Ext:

Email:

@ccri.edu

Employee Role:

Faculty  Staff   Student Help

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:

Access to:     Test Production

Data Access Office Signature:

Date:

IT Dept. Completion Date and Initials: