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Community College of Rhode Island

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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
Staff Other

**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:_____________

IT Use Only: Date Acct. Created: _____________  Acct. Termination Date: __________ Initialed:_________

Please print the form, complete it and return it to the Help Desk

Last Updated: 6/16/15