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									                                         Georgia Southern University
                                     Information Technology Services

Post Office Box 8136                                                                             TEL: 478-5429
Marvin Pittman Administration Building                                                           FAX: 478-0272

Date:   September 17, 2012

Re:     Request for MySQL Account

Requestor’s Information:
      This is the person who will be responsible for the account. He/She will act as authority for the account and
      should problems occur will be contacted. He/She should be a full-time Staff or Faculty member of Georgia
      Southern University. He/She may not be a student, graduate student, part-time or temporary staff member.

Account information:
      The organization name is the official name of your department, student organization or faculty/staff
      organization. Account Names and database names are assigned by the Account Management Department
      and typically will not change. The password can be reset by the department.

•      All forms and signatures must be filled out and signed by full time faculty or staff members of the University.
       Students in any capacity may not apply for official University accounts.

•       Departmental databases must have approval from their Department Head.

•       Student Organizations must have their faculty/staff advisor fill out the form, and have approval from the
        Director of Student Activities. These requests should be sent to the Director of Student Activities, Carter
        Walton at PO Box 8066.

•       Faculty Organizations must have approval from the Office of the Vice President of Academic Affairs. After
        approval, these requests should be sent to the VP for Information Technology Services, Steve Burrell at PO
        Box 8136.

•       Staff Organizations need to see the Vice President of their respective areas. After approval, these requests
        should be sent to the VP Information Technology Services, Steve Burrell at PO Box 8136.


       All information on the form must be completed with the authorizing signatures. The account will not be
processed without these signatures. Please return the completed forms to IT Services, PO BOX 8136, ATTN:
Account Management, or fax them to 478-0272.

        If you have any questions, please contact Accounts Management at 478-5429.
                                    MySQL Account Request
                                                Requestor’s Information

 (Please Check ONE box):                         Departmental  | Student Org  | Faculty/staff Org 

        Name (Page-Master/Advisor)

                               Eagle ID

                    Campus P.O. Box

                        Campus Phone


  Georgia Southern E-Mail Address                         

                                                  Account Information

 Organization Name

                                   Department or Organization requesting the account

 Description of database

                                   Type of DATA that the database will be used to collect or provide

Please read the following:

I hereby state that I am a member of the Georgia Southern University Faculty or Staff and that I will follow all Georgia
Southern University Policies and Procedures governing the use of Georgia Southern and University System computer
resources and facilities.

Furthermore, I understand that the use of this database for commercial purposes (advertising, soliciting, etc) is forbidden
and I agree to follow the Georgia Southern University Policies and Procedures governing the use of computer resources
and facilities for such activities.

Please sign and date that you understand and will follow these policies:

 Applicant Signature:                                                                 Date:

VP for Information Technology Services (Signature Required for Faculty or Staff Organizations)

 Signature:                                                                           Date:

Authorizing Agent’s Signature: (request will not be processed without this signature)
        Department Head for Departmental Requests
        Vice President’s Agent for Student Organizations (Carter Walton, Asst Director)
        Vice President’s Agent for Faculty or Staff Organizations (Check with Provost’s office)

 Signature:                                                                           Date:

 E-Mail Address:                


CASE #: ________________ PASSWORD: _______________ SFUPDATE: ___ NOTIFICATION SENT: ____________

USERNAME: ________________________                 DATABASE NAME: _____________________________
                                                                                                              Revised 09/11

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