Email Account Change Request Form



** = Indicates that the "Current" field is required 
Information on User  

Current   New   
First Name:    
Middle Name or Initial:     
Last Name:    
Primary Work Address:    
Zip Code:    
Budget Code:    
Phone Number:       
E-Mail User Name:       
Add Groups?  
Remove Groups?  
Special Instructions?  


Information on Requester  

First Name:        
Last Name:        
 E-Mail Address:        
** Are you Authorized to make this change?             

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