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Guest Access Identity Verification (DOC)

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					                   Guest Access Identity Verification
                   The University of Texas Health Science Center at Houston


Last Name: _____________________________
First Name: _____________________________
Middle Initial: _____________________________
UTHSC-H Sponsor’s Name: _____________________________
Department: _____________________________

I request “guest” a digital identity credential issued by The University of Texas
Health Science Center at Houston (UTHSC-H) in order to access certain non-
public, UTHSC-H information resources. In accordance with the requirements for
“guest” access, I have read the Information Resources Security Manual and will
sign the Information Resources Security: Acknowledgement Form in the
presence of a Notary. I have also presented the Notary only one of the following
valid, current primary Government Picture ID that contains my picture.

Driver’s License       _________               ____________           ____________
                       State                   Number                 Expiration Date

Passport               _________               ____________           ____________
                       Country                 Number                 Expiration Date

In order to receive my “guest” access to The University of Texas Health Science
Center at Houston information system, I must also furnish the following
information:

Birth Date: _____________________________
Country of Birth: _____________________________
Gender: _____________________________
City of Birth: _____________________________
US Citizen? (Y/N) _____________________________
Country of Citizenship: _____________________________
Home Phone: _____________________________
Work Phone: _____________________________

E-mail Address:
    Use new UTHSC-H E-mail Address? (Y/N)
       _____________________________
    Or, forward to an existing E-mail Address:
       _____________________________




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Employer: _____________________________
Street Address: _____________________________
Work City: _____________________________
Work State: _____________________________
Work Zip: _____________________________

Emergency Contact Information
      Emergency Notification Opt Out
OR
Emergency Cell Phone (xxx-xxx-xxxx): __________________________


I further understand that I will be listed in the university directory service as a
guest if I will have non-public access to any university information resources.

                                  Signature:    __________________________
                                  Address:      __________________________
                                                __________________________
                                  Date:         __________________________

STATE OF _________
COUNTY OF ________

      Before me, ________________, a notary public, on this day personally
appeared ___________________, known to me to be the person whose name is
subscribed to the foregoing instrument and acknowledged to me that he/she
executed the same for the purposes and consideration therein expressed.

Given under my hand and seal of office this ___ day of ___, 2011.



                                          ________________________________




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