Student Account Request Form

This form should be used to request, change or delete student accounts. Accounts available for students on this form are:

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

The fields with an asterisk (*) must be filled out.

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

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?

Other Information: