Slate Access Request Form

Employee ID

First Name

Last Name

Preferred Name

UMSystem Email Address (not Alias)

Title

Department or Office

Office Phone Number

Request Type:

This access request is for:

Me

Someone Else

New User's First Name

New User's Last Name

New User's Preferred Name

New User's UMSystem Email

New User's Employee ID

New User's Title

New User's Department

New User's Phone Number

Reason for Account:

What change would you like to make?

USER AGREEMENT By signing this application, I agree that I will not copy, nor disclose to any party, (Missouri S&T employee, Missouri S&T student or anyone else) confidential information, including licensed software residing on the Missouri S&T computer systems, my access codes and/or passwords. I agree to treat as confidential, all programs, files and information residing on any programs and files to which I have been granted access. I further agree to keep confidential any and all data or information, whether in electronic or printed format, in accordance with the policies and procedures of Missouri S&T and any district, state or federal laws. This includes the confidentiality of information concerning Missouri S&T's students, employees, vendors, and donors as well as Missouri S&T’s proprietary information. The confidentiality of student records is defined in the provisions of the Family Educational Rights and Privacy Act, as amended (20 U.S.C. 1232(g)), and with the regulations issued there under by the U.S. Department of Education

Yes

No

Signature

Slate Access Request Form

Please complete this form to request Slate access. All fields are required.

Missouri University of Science and Technology

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