<p> ABSS E-mail and Network Account Request Non ABSS Employees and Special Accounts</p><p>Administrative Information (to be completed by administrator approving request): Name of School/Department ______</p><p>Name & Title of Administrator ______</p><p>Beginning date of service for non-employee ____/____/____ Ending date of service for non-employee ____/____/____</p><p>Signature of Administrator: ______Date______</p><p>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) ______</p><p>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.</p><p>______Signature of non-employee Date Return completed form to the Technology Department Attn: Julie Cozort Phone: (336) 570-6060 x20010 e-mail: [email protected]</p>