Request for Non-Patron Directory Account

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:

Zip Code:

User’s Full Name

Date

Policy

*Use of this account is to be consistent with University Policy 4009.01 and Ohio Revised Code 2913. Your signature above indicates that your use of this account will comply with all policies and laws governing the confidentiality of student and employee data. Violations, including improper use of system resources, will result in legal and/or disciplinary action. You are solely responsible for activity on this account. The sharing of User IDs and passwords is prohibited and is not considered proper authorization for use. Account activity is monitored.

Section 2: SERVICE TYPE AND INTENDED USE

Select one service type and describe need below

Requested Start Date:

Requested End Date:

Requested Services: