Elizabeth City State University | Information Technology
3
Rd
Party Account Access Request
This request is for accounts and/or resources for 3rd Party Vendors, Consultants, or Guests of Elizabeth City
State University. Accounts may only be requested and granted for guests, vendors, or consultants who require
access to university resources for official university business. Do not request accounts if they are not required).
This access can be provided for up to one year; accounts will terminate after one year. If no end date is given
access will terminate in 30 days. In order to prevent disruption of access, a new request must be submitted
prior to end date. The end date will automatically be used for account termination.
Request Type:
New
Renewal
Termination
Begin Date:_________ End Date:__________
Last Name:_______________________________________First:_______________________________MI_____
Company: ___________________________________Title:__________________________________________
Phone:_________________________________ Email Address:_______________________________________
Address:____________________________________________________________________________________
ECSU Contact person_____________________________ Department__________________________________
3rd Party Data
(To be completed by requestor)
Person and department you are working with
Note: The following data fields are required in order to prevent creation of duplicate accounts. All information
is confidential.
Cell phone:______________________________________________ Last 4 of ssn:_______________________
Account Access
Banner (INB)
RMS
SQL
VPN
WebFOCUS
Domain Account Only (no email)
Other_________________________________
Module
Admissions
Advancement
Finance
Financial Aid
General
Human Resources
Student
Student Accounts
Provide a brief justification and functions to be performed, also if access is needed for more than one
module, please justify:
ECSU Authorization
STOP - To be completed by ECSU sponsoring department – continue to page 2
Last name:____________________________________ First name:___________________________
Department:_______________________ Ext._______ Email address:_____________@mail.ecsu.edu
As the sponsoring department representative, I approve the access requested by the above contractor/consultant. When the
user leaves the university and/or completes their obligation to the University, I will notify Information Technology, so the
access is terminated. *Note: If Banner access is needed, send request to the appropriate Module Security Administrator.
Signature:_____________________________________________Date:_________________________
Scan and email completed forms to helpdesk@ecsu.edu or fax to 252-335-3447
Elizabeth City State University | Information Technology
3
Rd
Party Account Access Request
The undersigned third‐party vendor or contractor (the "Contractor"), in the course of providing certain
services to Elizabeth City State University (the "University"), may have access to or may acquire confidential
personally identifiable information, including but not limited to student and/or employee names,
addresses, telephone numbers, bank and/or credit card numbers, social security numbers, and income and
credit history information.
Confidentiality and Non‐disclosure Agreement
(To be completed by requestor)
Contractor warrants that it is familiar with the requirements of various state and federal laws regarding privacy
and security of confidential information maintained by the University, including the Financial Services
Modernization Act of 1999 (the Gramm‐Leach‐Bliley Act), the Family Educational Rights and Privacy
Act (FERPA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Payment Card
Industry (PCI) Data Security Standards, and the North Carolina Identity Theft Protection Act, and agrees
that it shall cooperate, and shall cause its officers, employees, agents, and subcontractors to cooperate
with the University, as necessary, to comply fully with these legal obligations.
Contractor agrees to keep confidential all student education records, employee personnel records, and
other personally identifiable information which is deemed to be confidential in accordance with applicable state
and federal law and standards, and will require that its officers, employees, subcontractors, and agents comply
with the same.
Contractor warrants that it is capable of safeguarding any confidential information accessed or acquired.
Contractor agrees that it will implement such safeguards as necessary to maintain the security and
confidentiality of the information accessed or acquired, and that it will prevent the disclosure of the information
except as required by law.
Contractor will immediately report to University any unauthorized use or disclosure of the accessed or
acquired confidential information.
Contractor, by requesting a remote access account, shall install or already have installed virus
protection software on my remote (this includes business, home or laptop) system. In addition, I
authorize ECSU to perform random port scans to assess the security when needed of my connection to
the ECSU network. Installation of the virus protection and applying virus signature updates is my
responsibility.
Contractor shall indemnify, protect, defend, and hold harmless the University and its trustees, officers,
agents, employees, representatives, and assigns, and the University System of North Carolina and its
governors, officers, agents, employees, representatives, and assigns from and against any and all claims,
demands, suits, and causes of action and any and all liabilities, costs, damages, expenses, and judgments
incurred in connection therewith (including but not limited to reasonable attorney's fees and court costs)
relating to or arising out of Contractor's or Contractor's authorized representative's unauthorized use or disclosure
of confidential information.
I certify that I have completed this request fully and accurately to the best of my knowledge. I have read and
agree to comply with the policies and procedures concerning the usage of the ECSU Information Systems. I
understand that access to these systems is to conduct official university business and that the information that is
available to me is not for personal or commercial purposes.
Printed Name:_____________________________________________________________________________
Signature:_____________________________________________________________ Date:______________
IT
Official use
ONLY
Send your completed request back to your sponsoring department for authorized signatures
IT Ticket created: ______yes ______ no
Were multiple Tickets created?: _________yes _______no
Date Created:____________________ Created by:____________________________________________
Ticket #’s_________________ _________________ _________________ _________________
_________________ _________________ _________________ _________________
Last revised 06/01/15