Student Account Request Form

This form should be used to request, change or delete student accounts.

Faculty or staff should request accounts through the MSCNS web site.

Fields with an asterisk (*) are required fields.

 

Personal Information
*Name:
*Phone Number:
*Email address:
*Type of Student (select one):
Please choose from:
Medical, P/T, O/T, HAP, MSTP, DBBS, PACS, GEMS
Other (Please Specify)
*Expected Graduating Year
Check the accounts that you know you have currently:
NT(Domain Account)
Lotus Notes
Wireless
 
Pocket PC
Mac (OS X only)
PC Laptop
MacAddress
User Name for Account:
Service Requested:
If you are requesting a Wireless Account, please select one of the following:
I have a wireless card. Here is my MAC address:
I don't have a wireless card. I plan on purchasing one at the ITLS.
What operating system do you have?
Pocket PC
Mac (OS X 10.3 only)
Windows XP
Windows 2000
Windows ME/98
Other Information: Please provide as much information here as possible to service the request. (Please do not enter a carriage return or use your <Enter> key in the textbox below.)