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SOUTHWEST VIRGINIA COMMUNITY COLLEGE
INFORMATION TECHNOLOGY SERVICE CHANGE FORM
This form documents the process which grants, and removes, access to specified SWCC Information Technology resources.
Initial network access is based upon employee certification through completing security awareness training. This form is to be
completed and signed by employee’s supervisor and submitted to HR to begin the employee’s certification process. When an
employee leaves the college, this form must be submitted immediately to HR to remove user privileges.
Employee Name: _______________________________________ EMPLID: _______________________
_____Faculty _____Adjunct Faculty _____Staff _____PT Employee _____Intern _______________Other
Employee Home Telephone Number: ______________________________________________________
Name of Previous Employee in this position (if replacing): _____________________________________
Department Name: ______________________________________________
Supervisor’s Name: ______________________________________________
If other box is checked, list IT resources requested: __________________________________________
Reason for Access Change: _____New Account _____ Reactivation _____Deactivation _____ Account Removal
If requesting account removal, please provide last day of employment: _______________________
Requesting Copier Account: _____YES _____NO Charge Code: _____________________
If requesting copier account, please provide last 2 digits of employee’s SSN_________________
Requesting Phone Extension: _____YES _____NO
Room Number_____________ Existing extension number (if replacing a previous employee) _________________
This Account will be: _____Restricted _____Long Distance _____International
(Note: Restricted calling allows for local calls only. Long distance calls applies to calling within the United States
and international calling applies calling outside the United States.)
For SIS (Student Information System) access, employee’s supervisor must submit the SIS Security Request Form.
Supervisor’s Signature ____________________________________________ Date _________________
--------------------TO BE COMPLETED BY HUMAN RESOURCES--------------------
_____Change Approved _____Change Denied Notes: _________________________________
Human Resources Signature ____________________________________ Date __________________
Revised 02/2014
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