Employee Information

Employee Name:

 

 

Date:

 

Time:

 

 

Employee Number:

 

 

Employee’s Phone:

 

 

 

 

Department:

 

 

Location:

 

 

Manager’s Name:

 

 

Manager’s Phone:

 

 

Manager’s Signature

 

 

(Manager’s signature is required for approval.)

 

 

 

Employee Status

(Please select one of the following.)

Full-time

 

Contractor

 

Part-time

 

Temporary

 

 

 

Access Requested

(Please check all network accounts the employee needs access to.)

Is this request for a change to an existing account or for the creation of a new account?

Existing

 

New

Network

 

Quick Books

 

Wireless/Treo

 

VPN

 

E-mail

 

LAN/Mainframe

 

Access

 

Remote

 

Other:

 

 

 

 

Applicant’s Signature

(The applicant’s signature is required.)

By signing this document, I signify that I have read, understand, and agree to abide by the company computer use policy.

Applicant’s Signature:

 

 

Date:

 

 

 

 

For Information Technology Services Use Only

Accounts created by:

 

 

Date:

 

Time:

 

 

Notification given by:

 

 

Date:

 

Time:

 

 

 

 

 

 

Please return this form to: Information Technology Services

 

Once created, all account information will be sent to the applicant. Please allow three business days for account creation. Direct any questions regarding your application for computer access to Information Technology Services.

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