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Accounts Proxy Registration Form
Information and Educational Technology
University of California, Davis
Accounts Proxy Registration
(please print)
Name:
Employee ID:
Department:
Location:
Code Word (please use only one word):
(to be used by IET Staff to verify proxy status)
Email Address:
Mailing Address (if different from department):
Campus Phone:
FAX:
I agree to administer certain services of University of California, Davis Information
and Educational Technology in compliance with its policies and the campus policies
applying to electronic communication.
Proxy’s Signature:
Date:
Unit Manager:
Unit Manager’s Signature:
Please fax this completed form to the IET Account Administrators at
(530) 754-8470
1 Updated 5/18/2006