August 4, 2016
Form 51
Page 1
Purdue University Northwest
PC Local Area Network Request for Access (F
orm 51)
Requester Information
Full Name:
PUID:
Department: Building/Room: Phone:
Regular FT/PT
Purdue Employee Tem
p. Staff Student Worker
Job Title:
Hire Date:
Access Requested
E-mail A
ccount Account
Privileges
for use by Staff of PNW Affiliates
for E
-mail Account Request Only
Default E-mail Lists
#PNW_All_Faculty_and_Staff, #PNW_Open_Forum
(A full list of available Lists and Owners can be found at www.pnw.edu/information-services/email-distribution-lists)
Default Network Drive Access
All_PNW_Staff, G_(your building), G_VPN_STAFF_NETWORKMODE
Additional Network Drive Access
Request access to: (i.e. G_FSOP, G_CSSAC)
Delegate Access
A
ccess to other mailbox:
for Account Privileges Request Only
Student Password Res
et/Unlock Accounts
Staff Password R
eset/Unlock Accounts
Full Time Server A
dmin Access
Student Server Admin Access
Full Time Operator
Student Operator
Server Privilege
Other (PCI Workstations)
for use by Staff of PNW Affiliates Request Only
Name of A
ffiliate:
Location: Building/Room: Phone:
Job Title: Ac
count Expiration Date:
You should read the IT Res
ource Acceptable Use Policy before you sign this form.
I accept the responsibility for protection of and correct use of any access granted me to any Purdue University Northwest data.
I agree to use my Purdue University Northwest accounts for computer activity related to employment at Purdue Northwest and
understand that account authorization is non-transferable and will be revoked upon termination of employment. I understand
the requirements stated in the IT Resource Acceptable Use Policy (http://www.purdue.edu/policies/information-technology/
viia2.html) and will follow them.
Requester Signature
Date
click to sign
signature
click to edit
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