Delegated Administrator Request Form

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					                                                                                          Date Submitted:   _____/_____/_____


                                  NYS Directory Service (NYSDS)
                               Delegated Administrator Request Form
Purpose:       This form will be used to request a new NYSDS Delegated Administrator (DA) account for your
               organization or application. The Delegated Admin account will only be used for administrative
               purposes such as creating/modifying user accounts by using the Delegated Admin Tool.

Audience: LDSS County Commissioners, and Application Owners (AOs). Note: If you are a PODSA then you
          are required to submit Delegated Admin accounts using the Delegated Administrator Tool
          (https://da.oft.ny.gov/da)

Instructions:
    1) Read the Directory account Management policy for information regarding CIO/OFT account
        management requirements. http://www.cio.ny.gov/Policy/NYSTechPolicyP03-001.pdf

    2) All fields are required, unless specifically marked as optional.

    3) If this account requires the same functionality as another Delegated Administrator’s account please
       include that Delegated Admin’s uid in Step 2, Clone UID Field.

NOTES:
     >The Administrative account will be considered the second account for the administrator. He or she will
     also need a regular user account that allows him or her access to the applications required to perform
     his or her daily tasks.

           >Be sure to mark the identification methods on page 3. For security reasons please do not attach
           copies of identification information.

           >Submit this form via your County Commissioner or Application Owner email account to
           nysds@cio.ny.gov using the following text as the Subject: Delegated Administrator Request Form.

           >Changes to existing Delegated Admin accounts should be sent by email to nysds@cio.ny.gov.


                                       Step 1 –Delegated Administrator Information
DA’s Name (Last, First, MI):

DA’s Email Address:

Desired DA Account User ID (optional):

Phone #:                             Mobile # (optional):                        Fax # (optional):

Street:                              City:                                       State:            Zip:

Country:                             County (if State=NY):
                                 Step 2 - Identify Delegated Administrator Abilities

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CLONE UID (Optional):

Directory Account Management Ability – (optional)
      Password Reset only

      Full PODA – (e.g., Create, Update, modify accounts, includes password reset ability)

List the Delegated Admin Account Scope:
The default is the requestor’s organization. Example: A request submitted by Orange County Commissioner would be scoped to
Orange County only, unless otherwise listed here:




Application Entitlement Ability (optional)
Please list the Full Name Of Application(s), comma separated, the admin will need to entitle for and the SCOPE or organization
unit that this ability is limited to: Example: Centraport Orange County


______________________________________________________________________________________________________


______________________________________________________________________________________________________


______________________________________________________________________________________________________


______________________________________________________________________________________________________


______________________________________________________________________________________________________




                                            Step 5 – Authorizer’s Information

Note: You must be the designated organization’s ISO, County Commissioner or Application Owner. PODSAs are Required to
submit Delegated Admin request via the Delegated Admin tool.
Participating Organization Name:

Print First and Last Name:

Signature:                                                                                   DATE: _____/_____/_____




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                                     Acceptable Forms of Identification
Purpose: This form documents the methods that were provided to verify the administrator’s identity.

Instructions: Mark the TWO identification forms submitted by the prospective delegated administrator. To
meet the trusted user requirements, the applicant MUST present acceptable identification to the certifier. All
forms of identification must be valid and unexpired.

The following combinations are acceptable for this trust level:
                  Two (2) Class A forms with a picture
                                                 -- OR --
                  One (1) Class A form with a picture PLUS one (1) Class B form
                                                 -- OR --
                  One (1) Class A form with a picture PLUS one (1) Class C form
                                                 -- OR --
                  Two (2) Class B forms, at least one (1) of which must have a picture
Class A
         U.S. Passport, with photograph and name of the individual
         Driver’s License or ID card issued by a state or outlying possession of the United States with photograph
            and name of the individual
         ID Card issued by US Federal, NY State or NY local government agency or entity with photograph and
            name of the individual
Class B
           Social Security Card
           Voter’s Registration Card
           Military dependent’s ID Card
           US Coast Guard Merchant Mariner Card
           Native American Tribal document
           Driver’s License issued by a Canadian government authority
           Unexpired foreign passport with I-551 stamp or attached INS Form I-94 indicating unexpired
            employment authorization
           Alien Registration Receipt Card with photograph (INS Form I-151 or I-551)
           Unexpired Temporary Resident Card (INS Form I-688)
           Unexpired Employment Authorization Card (INS Form I-688A)
           Unexpired Reentry Permit (INS Form I-327)
           Unexpired Refuge Travel Document (INS Form I-571)
           Unexpired Employment Authorization Document issued by the INS which contains a photograph (INS Form
            I-688B)
Class C
        Any form of identification, with the person’s name, which can be verified
        TYPE OF IDENTIFICATION: ___________________________________________________________

Print Authorizer’s First and Last Name:_____________________________________________

Signature:______________________________________________ Date:______________




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