Clm Account Request Form - Middle Tennessee State University
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1Print Form
CLM
Account Request Form
(Campus Loan Manager)
User ID_____________
ITD (Information Technology Division) Use Only
1. ______________________________________________________
MTSU ID#: ____________________
Last Name (print)
First Name
Middle
2. Department: ________________________________ Phone: ______________ Fax: ___________________
3. Job Title: _______________________________________________
Email: __________________________
4. My status (circle one):
Staff
Administrator
Other
5. This is a request to: ____ Create a new account
____ Modify my account (account name ____________________)
____ Remove an account (account name ___________________)
6. I need CLM access in order to: ___________________________________________________________
____________________________________________________________________________________
7. Acknowledgement of Confidentiality:
I certify that the accounts assigned will be used only for legitimate MTSU business and
that confidential information will not be released to any person who does not have a legitimate educational or business interest. I
understand that these accounts will be used in accordance with MTSU policy, including, but not limited to, MTSU Policy I:03:05
(Privacy of Information), MTSU Policy I:03:03 (Information Technology Resources Policy)**, Family Educational Rights and Privacy
Act (FERPA), Health Insurance Portability and Accountability Act (HIPAA), as well as State and Federal statutes. I will exercise
great care when dealing with sensitive information including, but not limited to, social security number, birth date, insurance or
patient identifiers, credit card information, etc.
**More information on ITD polices and Procedures may be found at
Applicant Signature: __________________________________ Date: _____________________
8. Authorization: As departmental representative, I approve the access requested above. If the requestor of this account
leaves this department and/or severs ties with MTSU, I will notify ITD to modify or remove the account as appropriate.
______________________________________
_______________
______________
Signature of Immediate Supervisor
Date
Phone
9. Route to the Manager-Student Loans in the Business Office, Cope room 103.
CLM Security Profile: _____________________________________________________________________
Exceptions to Profile: _______________________________________________________________________
Manager-Student Loans: ____________________________________
Date: ___________________
Trainer Certification: ______________________________________________
Date: ___________________
ITD USE ONLY
Implemented by: _________________________________________ Date: __________________
Reporting Access Implemented by: ____________________________ Date: __________________
Notified by: _____________________________________________ Date: __________________
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