UW-L Miscellaneous Email Account Request Form
MISCELLANEOUS EMAIL ACCOUNT REQUEST
DO NOT USE THIS FORM IF THE PERSON IN NEED OF AN EMAIL ACCOUNT
WILL BE PAID BY LUMP SUM PAYMENT OR UW-L PAYROLL
Directions:
Request must be approved/signed by a UW-La Crosse supervisor/chair. Please allow 7 working
days for processing. Complete form and submit via hand delivery in sealed envelope to Human
Resources 144 Graff Main Hall. Questions? Contact Shelle Gholson, x5-6499 or sgholson@uwlax.edu
DATA ELEMENTS
Please provide the following information for person needing email access:
Name:
Former Name (if applicable):
Date of Birth: (REQUIRED):
Unit/Department assigned:
Start Date:
End Date: (REQUIRED)
(must provide end date of 2 years or less)
Work to be performed:
Courtesy Scholar
Mil Sci Instructor of Record
Other (briefly describe): __________________
Cont. Ed Instructor of Record
Chartwells
Olsten Temp (briefly describe): __________________
Will this person be grading?
No
Yes (Department if different from assigned dept)
Is this person a former:
UW-L student
UW-L staff
Campus address and phone for on-line Directory, if applicable:
Access needed:
WISDM
Murphy Library
HRS Time & Labor Approver
Electronic room access:______________________
D2L (not grading)
Specify Building & Room Number
(UW-La Crosse ID card required for library and electronic room access.)
UW-L EMPLOYEE COMPLETING REQUEST FOR ACCESS
Name:
Department: _________________________________________
Phone: _____________________________________________
SUPERVISOR/CHAIR APPROVAL
Supervisor/Chair must sign to indicate their approval
Unit/Department Supervisor/Chair Signature
Print Name
HUMAN RESOURCES ONLY
APPROVAL/REVIEW
Date Received:
Date Input:
Date Inactivated:
HR Initials:
HR Initials:
IT ticket for email change, if necessary___________________
Rev. 09/2015
Date