Information Technology
User Account Request

Please Type


 First Name:   Middle Name:  Last Name:
 Phone:  Employee ID#
 Division/Dept.  Position/Title:



Employment Status:



  Contractor (Specify):                Start Date:             End Date:  






  Non-Privileged - E-mail, Internet, Z drive, etc.

  Privileged - Access to student records as a privileged user in Department/ Division

    Create this user with the same access as user (Specify Existing User Name): 


 Create Rosters+ account (specify department or division):
  OnBase Viewer     OnBase Scanner
For PeopleSoft Access, Please fill out a PeopleSoft Security Form in addition to this Form.


Dean/Director/Manager Name:  Date:


Dean/Director/Manager Signature: ________________________________________

To be completed by Information Technology:

User Name: __________________   Account: _______   Created By: _______________  Date:  ___________


Form Revision Date:  08/24/15