Name (First, Middle Initial, Last)*:

Title: Start Date*:

Department*:

Phone Number where you can be reached before September 1*:

E-mail address where you can be reached before September 1*:

Please select the account(s) needed:
BSC User Account/E-mail

WebHost (Personal Web Space)

Blackboard sites for your courses (online course management system)

Agreement:
I certify that I have read and understand BSC Security Procedures, BSC Responsible Use of Information Technology, and BSC Electronic Mail Policy; I understand that I am responsible for any computing activity carried out using this account. I agree to comply with the conditions of the policies listed above.

Human Resources Use Only: Banner ID: ________________ Effective Date(s) of Employment: __________ Approved by:_________ Date:__________ Information Technology Use Only: Username: __________________________ Expiration Date: ________________ Initial Password: _____________________ Must Change at Next Logon: ______ Email Address: _______________________ New Employee Email Sent: ________ Account Created By: __________________ User Notified By: _____________________ Date Created: ________________________ Date Notified: ________________________