Information Technology Account Request Form

This form is only for part-time faculty and all other staff and administrators.  Full-time faculty and librarians should use the form at http://www.bridgew.edu/Depts/AcAffairs/IT_account_request.cfm

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* 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) *
BSU User Account: _____
(Network/Domain Access)		 Email:_____
(Outlook Mail)		 WebHost (W:): _____ 
(Personal Web Space)		 VPN: ______
(Virtual Private Network)
Agreement: I have read and understand BSU Security Procedures, BSU Responsible Use of Information Technology and BSU 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 for NEW accounts should be returned to Human Resources first. 

Please return all other completed account request forms to the User Account Coordinator, Information Technology Division, 013 Boyden Hall or fax them to 508.531.1774.
Human Resources Use Only: Date HR Received form: ______________
Banner ID: ____________________ Effective Date(s) of Employment: _____________________
Information Technology Use Only:
Date IT Received Form:  _______________  
Username: _____________________________________ Expiration Date: ______________________
Initial Password: ________________________________ Must Change at Next Logon: ____________
Email Address: _________________________________ New Employee Email Sent: c
Account Created By: _____________________________ User Notified By: _____________________
Date Created: __________________________________ Date Notified:  _______________________
 

Last Modified: August 30, 2011