Non-Employee Access Request Form
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 (Solano Hall, Room 1123), Attention: Janet Korsmo.
What access does this person need?
Affiliation:
If vendor, company name:
Other affiliation:
Access Dates
Begin Date: End Date:
Maximum Duration of Access:
Auxiliary = 1 year
Volunteers, Vendors & Visiting Scholars = 6 months
(Access can be renewed, as needed.)
Has CMS Access/Compliance form been completed?
Requestor's Information: (To be completed by the person needing access. PLEASE PRINT)
Last Name:
Yes
No
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
Signature Date
Date
HR & Faculty Affairs Use Only:
POI Type Assigned: ________________ Business Unit: ________ Date Entered: _____________ Entered by:_____________
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:
Person ID:
Phone:
Zip Code:State:City:
Street Address:
First Name:Last Name:
Yes
No
End Date:Begin Date:
Access #3: MyCI, computer, email, printing, H: drive, faculty services
Access #2: MyCI, computer, email, printing, H: drive, ID card, library
Access #1: MyCI, computer, email, printing, H: drive
Other affiliation:
If vendor, company name:
Affiliation:
Extension:Contact:Department:
Person ID:
