Campus Domain Account Application Form
*Please print the form, complete it and return it to the Department of Information Technology, attn: Help Desk*
Last Name: ______________ First Name: _________________ Middle Initial:______ (Please Type or Print Clearly)
CCRI ID# * or MyCCRI Username ____________________________________ Date:_________
*Your CCRI ID# is the 8-digit number below your name on your Faculty/Staff or Student ID.
Title:_____________________________________________ Phone: ______________________
Department:_________________________________ Campus: __________________________
|Please check one of the following||Primary Use (Please check all that apply)|
|Faculty - full time||☑ Domain|
|Adjunct Faculty (part time)||Access to Dept. Share Drive|
**Student accounts are terminated at the end of the current semester.
Are you temporary: yes no If yes termination date:____________________________
Agreement: I have read, understand, and agree to comply with the CCRI Data Security Policy and the CCRI Policy on the Responsible use of Information Technology. I understand that I am responsible for any computing activity carried out using this account.
Applicant's Signature: __________________________________________ Date: _____________
Department Head's Signature:____________________________________ Date:_____________
Please print the form, complete it and return it to the Help Desk