Fillable Va Form 9957 - Access Form (Page 2 of 2) in pdf

Va Form 9957 - Access Form Page 2

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INSTRUCTIONS FOR COMPLETING THE ACCESS REQUEST FORM

1. Action Requested

ARE YOU CURRENT ON YOUR SIGNED RULES OF BEHAVIOR; CYBER SECURITY AND PRIVACY TRAINING? - If

current, check "YES". If "NO" is checked then access form can not be processed.

TYPE OF ACCESS - check appropriate box.

TYPE OF ACTION REQUESTED - check appropriate box.

2. Customer Information

The following are detailed instructions on completing this form. This form must be completed electronically. Block 4, Signature

Block, must have the name and title completed electronically, once the form is printed, all signatures must be ink signed.

Name - If VA employee, name must match name in PAID System.

Customer Identification (if for Austin main frame access enter seven (7) character Time Sharing Customer

Identification.

Telephone Number

Facility (Station) Number/Suffix

Mail Routing Symbol or Mail Stop Code

Job Title - Use the title from Position Description

Expiration Date - Optional for Contractors and Students

Employer - Required for contractors and anyone other than a VA Employee

Office Address - Required

Active Directory (AD) Username - Required for all employees and contractors

Active Directory (AD) Domain - Required for all employees and contractors

E-mail Address - Required for all employees and contractors

3. Access Requested

Please contact your facility point of contact or Information Security Officer for a list of functional task codes and requirements.

4. Signatures

The person approving the access can not be the person requesting the access.

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

BACK OF VA FORM 9957, APR 2008, PAGE 2 OF 2

Va Form 9957 - Access Form Page 2

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