New Email Account Request Form   

 
 
 Information of User
First Name:      
Middle Name or Initial:      
Last Name:       
Username:      
 
 Information on Agency
Agency:      
Department/Division:      
Address:      
                           City:      
                    Zip Code:      
Budget Code:      
Phone Number:      
 
 Information on Permissions and Groups
Mirror to User:      
     (To mirror another known user's email groups)
Add Groups:      
     (If more groups are needed, or no mirror is available)
Enable Communicator?      
Special Instructions       

Information on Requester
First Name:      
Last Name:      
E-Mail Address:      
 
 Information on Approving Authority
First Name:      
Last Name:      
E-Mail Address:      

   
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