User/System Account Access Request Form Legal First Name Legal Middle Name Legal Last Name Preferred Name (if applicable) Preferred Name (if applicable) First First Last Last Request Type New Account CreationAccount ModificationAccount TerminationEmergency Access (requires CIO approval) Employee/Student ID (if applicable) Department Position/Title Phone Email Start Date End Date (if temporary or contractor) Account Type Standard User AccountPrivileged Account (requires additional approval)System AccountService Account (requires System Owner approval)Temporary Account (maximum duration: 24 hours) Access Level Non-privileged (standard user)Privileged (administrative rights) – Requires justification User Type FacultyStaffStudentContractor/VendorGuestService AccountSystem AccountOther (specify): User Type Other (specify) Systems Access Required Remote Access Requirements No remote access neededVPN access requiredRemote desktop access requiredAfter-hours access requiredWeekend access required Reason for Remote Access Requested Security Groups Role(s) Required Basic UserPower UserDepartment AdministratorSystem AdministratorDatabase AdministratorNetwork AdministratorSecurity Administrator Role-Based Access Requirements Special Access or Exceptions Required If you are human, leave this field blank. Submit
