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Banner Student Authorization Request Form

Return to:

• Stacey Flowers, Flanagan Campus for CWCE
• Dennis Grassini, Knight Campus for Business Division
• Melissa Braun, Flanagan Campus for Student Affairs and all other departments

Please provide the following information:

Date:

 

CCRI ID:

 

First, MI, Last Name:

 

*Title:

 

*Please indicate if you work through a Temp Agency

Department:

 

Campus:

 

Phone Extension:

  

E-mail:

 

Employee Role:

 Faculty  Staff   Student Help Intern / Volunteer

If Intern / Volunteer:

 Date Begin: Date End:

Account Type:

 New  Terminated   Change

If account changed, what is reason?

 

Agreement: I have read, understood, and agree to comply with FERPA regulations, 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. Access to Banner Student will be activated upon completion of all training.

Applicant's Signature: _____________________________ Date:_________________

Supervisor's Signature: _____________________________ Date:_________________