Cg-7421d - Imagenow User Access Authorization

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DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard

IMAGENOW USER ACCESS AUTHORIZATION

Please fill out online or print neatly! This authorization supercedes previous applications.

2. Rank/Rate

3. Employee ID # (Not SSN)

1. User’s Name (Last, First, MI.) (Please print or type)

4. Dept ID & Unit Name (Include Staff Symbol)

5. Area Code & Phone Number

6. e-mail Address

7. User Role Description (Include current roles, this authorization supercedes all of your previous authorizations):

PPC General:

RAS:

Accounting Techs

ACT/RES Pay Techs

Annuitant Pay Techs

FAR:

Records Review-KS

Admin

Supervisor/Auditors

View & Print

Member Record Review

View Only

OTHER:

(describe below)

SES:

ADT

IDT

SOCS

ADT View & Print

IDT View & Print

SOCS View & Print

ADT View Only

IDT View Only

SOCS View Only

TVL:

Claim Examiners

System Support

View & Print

View Only

Security Administrators:

Administrators:

CS User Auth – DA & JUMPS User Auth Forms

ID AIS

ImageNow Administrator

Scanners

HQs/PSC/SPOs:

Document Processors (Scanners/Image Processors)

PSD-MR

OPM-3

Boardroom Administrators

Records Review – Full Access

OPM

RPM (Officer Records)

OPM/RPM Boardroom Accounts

BCMR/Congressional Review

Auditor Support

Records Review – Restricted Access

SPO IPDR

EPM

RPM (Enlisted Records)

CG HQs (limited)

PPC

8. Authorizing Official (Signature & Typed or printed name, Rank, Title (CO/OIC, XO/XPO or HQ/DCMS/CGPSC/FORCECOM/OPCOM/DIST, Branch Chief)

& Phone Number):

I certify that the access I have authorized is based on an official need. I’m aware of the general functionality I have authorized and I’m aware of what this will

allow this member to complete. If this is for a contractor, the Contracting Officer’s Technical Representative (COTR) sign as AO.

________________________________________________________________________________________

___________________________

Signature, PRINTED or TYPED Name, Rank,

Title (see instructions),

Phone

Date

Privacy Act Statement

Execute Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

AUTHORITY:

To record names, signatures, and other identifiers for the purpose of identifying individuals requesting access to U.S. Coast

PRINCIPAL PURPOSE:

Guard (USCG) systems and information. NOTE: Records may be maintained in both electronic and/or paper form.

None.

ROUTINE USES:

Disclosure of this information is voluntary; however, failure to provide the requested information may impeded, delay or

DISCLOSURE:

prevent further processing of this request.

Acknowledgment: I understand that I am authorized to access the ImageNow/WebNow system and that accessing it for purposes beyond the Scope of

Authorization is a violation of Federal law (18 U.S.C. 1030 et al) (Note: Refer to the Automated Information Systems (AIS) User Acknowledgment Form (CG

5500A), which is required for all U.S. Coast Guard AIS users, it contains the full Scope of Authorization and Acknowledgment.)

11. Date

10. User’s Signature

Fax to: (785) 339-2297

Revocation Procedure:

ImageNow access must be terminated upon PCS, separation, retirement, reassignment of duties (Fleet-Ups) and change of organization (inter-office

transfer). Contact PPC Customer Care via on-line trouble-ticket at

or via email at

PPC-DG

CustomerCare@uscg.mil

for all ImageNow account revocations.

CG-7421D (9/11)