Non-Employee Access Request Form
Person ID:
Department: Contact: Extension:
Instructions: Complete this form to give campus systems access to non-employees. All fields must be completed.
Incomplete forms will be returned to the department and access may be delayed. Submit completed forms to
Human Resources Programs (Lindero Hall, Room 2801), Attention: Martha Ferguson.
Affiliation:
If vendor, company name:
Other affiliation:
What access does this person need?
Access #1: MyCI, computer, email, printing, H: drive
Access #2: MyCI, computer, email, printing, H: drive, ID card, library
Access #3: MyCI, computer, email, printing, H: drive, faculty services
Other:
Access Dates
Maximum Duration of Access:
Auxiliary = 1 year
Begin Date: End Date:
Volunteers, Vendors & Visiting Scholars = 6 months
(Access can be renewed, as needed.)
Has CMS Access/Compliance form been completed?
Yes No
Requestor's Information: (To be completed by the person needing access. PLEASE PRINT)
Last Name: First Name:
Street Address:
City: State: Zip Code:
Phone: Date of Birth: Social Security Number:
Home Email Address:
Department Authorization: (To be completed by the department. PLEASE PRINT)
Reason for request:
Supervisor's Name:
Division Head's Name:
Signature
Date
Signature Date
HR & Faculty Affairs Use Only:
POI Type Assigned:
Business Unit:
Date Entered:
Entered by:
