Fillable Va Form 9957 - Access Form printable pdf download

Va Form 9957 - Access Form

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ACCESS FORM

PRIVACY ACT STATEMENT: The information is solicited under authority of Title 38, United States Code and Executive Order 9397 and is

necessary to accomplish the action requested by the requester, including establishing, modifying or deleting a Customer Account. Furnishing the

information on this form is voluntary; however, if the information is not furnished, we will be unable to take further action on your request.

NOTE: Information from this form is used to establish VA Accounts or to grant access to VA resources.

ARE YOU CURRENT ON YOUR

TYPE OF ACCESS

TYPE OF ACTION REQUESTED

SIGNED RULES OF BEHAVIOR;

CREATE NEW CUSTOMER

CYBER SECURITY AND

ZOS (Mainframe)

WINDOWS

PRIVACY TRAINING?

MODIFY EXISTING CUSTOMER

UNIX

DATABASE

LAN ACCOUNT

DELETE EXISTING CUSTOMER

NSSD

YES

USD

OTHER (Specify)

2. CUSTOMER INFORMATION

A. NAME (Last, First, Middle Initial)

B. CUSTOMER ID

C. TELEPHONE NUMBER (Include Area Code)

D.STATION (FACILITY) NUMBER

E. MAIL ROUTING SYMBOL

F. JOB TITLE

OR STOP CODE

G. CONTRACTOR, OR IF TEMPORARY ACCESS, SHOW

H. CONTRACTOR OR OTHER GOVERNMENT ORGANIZATION, NAME EMPLOYER

EXPIRATION DATE (Month, day, year)

I. CONTRACTOR OR OTHER GOVERNMENT ORGANIZATION,

J. ACTIVE DIRECTORY (AD) USERNAME

K. ACTIVE DIRECTORY (AD) DOMAIN

OFFICE ADDRESS (Street, City, State, Zip Code)

L. E-MAIL ADDRESS

NOTE: See reverse for instructions.

3. ACCESS REQUESTED

CHECK

NAME OF FUNCTIONAL TASK CODES; PROFILES, WEB

APPROPRIATE

DEFINE LEVEL OF ACCESS REQUESTED OR CONCURRING SYSTEM MANAGER OF

SERVERS; UNIX ACCOUNTS; DATABASE OR OTHER

BOX

RECORD (SMR) DESIGNEE SIGNATURE AND TITLE (If required)

ACCESS

ADD DELETE

110NN01 – Scrambled SSN Workload

110NN07 –PHI Workload

110TT10 – DSS

110AL99 – PHI DSS

4. SIGNATURES

A. REQUESTING OFFICIAL & TITLE

B.DATE

For temporary access for Course 3 signature not necessary

XXXXXXXXXXXXXXXXX

C. APPROVING OFFICIAL & TITLE

D. DATE

For temporary access for Course 3 signature not necessary

XXXXXXXXXXXXXXX

E. SECOND APPROVING OFFICIAL & TITLE (If required)

F. DATE

For temporary access for Course 3 signature not necessary

XXXXXXXXXXXXXXXXXXX

G. NAME AND TITLE OF FACILITY POINT OF CONTACT OR INFORMATION SECURITY OFFICER

For temporary access for Course 3 signature not necessary

VA FORM

All prior editions of VA Form 9957 are not acceptable for submission.

9957

Adobe LiveCycle Designer 7.1

APR 2008

Va Form 9957 - Access Form

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