Section 1: USER INFORMATION AND ACCEPTABLE USE AGREEMENT Name (last, first,middle initial): * Date of Birth: * University Affiliation: Off-Campus Phone: On-Campus Department: University Extension: Current Email Address: * If provided, account information will be directed to current Email address. Confirm Current Email Field * Off-Campus Mailing Address: Street: City: State: - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: User’s Full Name * Date Date * Year Year20222023202420252026 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Section 2: SERVICE TYPE AND INTENDED USE Select one service type and describe need below Type 1: Network Login OnlyType 2: Type 1 with EmailType 3: Type 2 with Blackboard Requested Start Date: Requested End Date: Requested Services: Access to participate in the College for the Over-Sixty during the Fall 2022 semester. Section 3: SPONSOR APPROVAL (signature of responsible University Employee) Name (last, first, middle initial): Extension: Department: Sponsor Signature Date Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
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