ABSS E-Mail and Network Account Request Form/Agreement

ABSS E-mail and Network Account Request Non ABSS Employees and Special Accounts

Administrative Information (to be completed by administrator approving request): Name of School/Department ______

Name & Title of Administrator ______

Beginning date of service for non-employee ____/____/____ Ending date of service for non-employee ____/____/____

Signature of Administrator: ______Date______

Personal information of individual requesting account: (Please Print) First Name ______Middle Name ______Last Name ______Birthdate ______Last 4 digits of SS# ______Phone ______Reason for Request:  Name of Company or Agency ______ Substitute Teacher  Other (describe) ______

By signing below, I certify that: 1. The above information is accurate. 2. I understand the account privileges are valid only during the time my services are needed with the Alamance-Burlington School System. 3. I agree to follow the terms and conditions of the Alamance-Burlington School System’s Staff Acceptable Use Policy. 4. I understand my account privileges can be terminated at any time if I fail to comply with said policy.

______Signature of non-employee Date Return completed form to the Technology Department Attn: Julie Cozort Phone: (336) 570-6060 x20010 e-mail: [email protected]