Information Technology Account Request Form

* Indicates required fields
Applicant's First Name*: __________________    Middle Initial: ___    Last Name*: ___________________

Title: _____________________________________________________    Start Date:  ________________

Department*: _______________________________________________   Phone:  ___________________

Please select the appropriate role *
Faculty: ____  Staff: ____  Visiting Lecturer: ____ Grad Student: ____ Club: ____
  Contractor: _____ Affiliate: _____

Please select the type of request *
New Account**: ____ Name Change: ____ Status Change: ____ Renewal: ____
Print Previous Name: ______________ (Student to Staff/Faculty?)

Please select the account(s) needed (You may select more than one) *
BSC User Account: _____
(Network/Domain Access)		 Email:_____
(Outlook Mail)		 WebHost (W:): _____ 
(Personal Web Space)		 VPN: _____
(Virtual Private Network)
Agreement: I have read and understand BSC Security Procedures, BSC Responsible Use of Information Technology and BSC Electronic Mail Policy; I understand that I am responsible for any computing activity carried out using this account. I agree to comply with the conditions of the policies listed above.

Applicant's Signature*: ____________________________________________        Date*: _____________

Department Head Signature*: _______________________________________        Date*: _____________

Department Head Print Name*: _____________________________________
**Completed forms should be returned to Human Resources.
Human Resources Use Only: Date HR Received Form:  _____________
Banner ID: ________________ Effective Date(s) of Employment:  ______________________
Information Technology Use Only:
Username: _____________________________________ Expiration Date: ______________________
Initial Password: ________________________________ Must Change at Next Logon: ____________
Email Address: _________________________________ New Employee Email Sent:
Account Created By: _____________________________ User Notified By: _____________________
Date Created: __________________________________ Date Notified:  _______________________

Last Modified: July 2, 2008