STATE OF GEORGIA
APPLICATION FOR MAINFRAME RACF USERID Please type or print LEGIBLY. (Illegible forms will be returned.) 1.
APPLICANT'S FULL LEGAL NAME:
Last
First
Middle
2. APPLICANT’S MOTHER’S MAIDEN NAME: 3. AGENCY/DIV: ADDRESS:
4. RACF USER ID YOU ARE REQUESTING (7 CHARACTERS): 5. Employee
(check one):
STATE Employee
DEFAULT GROUP: CUSTOMER/NON STATE
CONSULTANT
****** (IF YOU CHECKED anything other than state (ABOVE) PLEASE EXPLAIN)
6. REQUESTED ACCESS: TSO SYSTEM A
TSO SYSTEM B
TSO SYSTEM D
Note: Any other application connections are the responsibility of the Group Security Administrator. NOTE: YOUR SIGNATURE SIGNIFIES AN UNDERSTANDING THAT YOU ARE PERSONALLY RESPONSIBLE FOR ALL ACTIONS TAKEN BY YOUR USERID, AND YOU ARE REQUIRED UNDER GEORGIA LAW TO PROTECT THE CONFIDENTIALITY OF YOUR PASSWORD. 7.
DATE
Phone (
)
APPLICANT SIGNATURE
8.
DATE
USERID
Phone (
)
DATE
USERID
Phone (
)
SUPERVISOR AUTHORIZATION (IF APPLICABLE)
9. AGENCY RACF ADMINISTRATOR
NOTE:
PLEASE FAX A COPY OF ALL ID REQUESTS TO 404 651-5006 I would like the above ID DELETED. DATE
USERID
AGENCY RACF ADMINISTRATOR
GTA (ITS) 599
Georgia Department of Education July 2015 “USDA is an equal opportunity provider and employer.”
Phone( FAX(
) )
OTHER