Account Request Form For Faculty/Staff by ZSsIui


									                         Retired Faculty/Staff Account Request Form

                                                        Retiree’s Information


                                           Eagle ID

                                   Home Address

                                     Home Phone

                      Department Retired From

Please choose one of the following patterns              for the Username, where F=first initial, and M=middle initial:

                                                         FLastname          FMLastname           FirstnameLastname
            Requested Username – 1 Choice

            Requested Username – 2             Choice

I hereby state that I am a retired member of the Georgia Southern University faculty or staff, and that I will follow all the Georgia
Southern University Policies and Procedures governing the use of Georgia Southern and University System computer resources and
facilities.   You       may        refer    to    a     copy       of     the      GSU       Computer         Usage       Policy       at I agree that my use of any e-mail account provided by
Georgia Southern University shall be in accordance with all applicable laws, regulations, and policies, including but not limited to the
Georgia Computer Systems Protection Act, O.C.G.A. Sections 16-9-90 et seq. You may refer to a copy of this at

I understand that I will be assigned a username and password for my use only and that I will not cause them to be known or us ed by
another person or persons. I recognize that access to any university resource is a privilege granted to me by Georgia Southern, and I
understand that I am solely responsible for the security of the assigned username and password. I will notify the Georgia Southern Help
Center at (912) 478-5429 in the event that this security may have been compromised. I also understand that periodic audits of my
activities on any such resource may be made by the systems administrator.

Signature: _______________________________________ Date: _________________________

You may fax the completed form to (912) 478-0272,
or mail it in a sealed envelope to:
GSU Computer Center
Attention: Retired Fac/Staff
P.O. Box 8136
Statesboro, GA 30460-8136


CASE #: _______________ ACCOUNT:____                    ________________________ PASSWORD: _______________ EID:                ___

NOVELL CONTEXT: __________RETIREE.GASOU_____________ ________________ SFUPDATE:                    DATE LTR SENT: _ ___________

                                                                                                                      Revised 10/09

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