Fillable Account Request Form Template - Kentucky State University printable pdf download

KENTUCKY STATE UNIVERSITY

Information Technology

Banner Access Request Form

FINANCE (F)

Today’s Date: _______________________ Applicant’s Starting Date: _______________________

Applicant Information

(Please print neatly)

First Name: _______________________________________ Middle Initial: ______ Last Name: ___________________________________

Title: ___________________________________________________________________________ CWID: ___________________________________

Division: _________________________________________________ Department: __________________________________________________

Office Location: Building: ______________________________________ Room: __________________

Phone: ___________________

Supervisor Name: _________________________________________________________________________

Phone: ___________________

Status:

Faculty

Staff

Student

Other ______________________________________________________________

New Employee

Transfer (From What Department? __________________________________________________)

Permanent

Temporary (Anticipated End Date of Appointment: _______________________ )

I understand that all information system accounts assigned to me at the request of my supervisor are to be

Applicant Acknowledgement:

used only in connection with my assigned duties as an employee of the University and may be revoked upon

the request of my supervisor. I understand and accept the following terms and conditions (please check

each paragraph):

____ I understand that passwords are the first line of security on all accounts. I agree not to reveal my

passwords nor allow anyone else to use the accounts assigned to me.

____ I understand that the disclosure of records, documents or other facts containing personally identifiable

information about students is prohibited by the Family Education Rights and Privacy Act of 1974. I also

understand requests for information about individuals, or requests for lists of individual students, are

to be forwarded to the University official responsible for maintaining the information and questions

concerning the release of information should be referred to the official. I have read and understand the

information provided.

I understand that the accounts assigned to me may provide me with access to sensitive, restricted, or

confidential data. I will maintain the confidentiality of any and all data that I retrieve from the

information systems in the course of my job duties, including data that I use for reporting purposes or

in other software products. I acknowledge that I fully understand the disclosure of information to any

unauthorized person could subject me to the criminal and civil penalties imposed by the law.

I further acknowledge that willful misuse of, or unauthorized access to, University information systems

also violates the University’s policy and could constitute just cause for action by the institution

regardless of whether criminal or civil penalties are imposed.

Applicant’s Signature: ___________________________________________________________________

Date: _______________________

Supervisor’s Signature: _________________________________________________________________

Date: _______________________

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Account Request Form Template - Kentucky State University

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