2. NOTE: this form is to be used to authorize the initiation or termination of certain computer access privileges. Upon completion by the affected department, it should be forwarded to the IT department for implementation.
4. Employee Status*

   1. Authorization
   2. Termination
   3. Dept Transfer
   4. Name Change only
6. Employee Name*
7. STAR# or ID#
9. Department*
10. Divison*
12. Is this employee authorized for access to Email?*

    1. Yes
    2. No
14. Is this employee authorized for access to the Internet?*

    1. Yes
    2. No
16. To what phone extension will this employee be assigned?*
18. In what room will the new employee be stationed?*
20. Key Card Assigned # (new hire info)
    Assign card from former employee in this position or get a new card # from IT
22. Key Card Returned (upon termination)
24. Effective Dates*
26. Form Submitted By*
28. Text/Narrative/Additional Info
    Use this field to explain specific access to systems or what to do with employee data post-termination.
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field