Online Application Login Request Form Online Application Login Request Form printable pdf download

ONLINE APPLICATION LOGIN REQUEST FORM

Office Holder Name: __________________________________________________ E-Mail: _______________________________________

Office: ___________________________________________________________________________________________________________

Phone: ____________________________________________________ Fax: __________________________________________________

Signature of Office Holder: _____________________________________________________ Date: _______________________________

USER INFO

USER INFORMATION SECTION

RMATION SECTION

PLEASE PRINT CLEARLY ALL INFORMATION EXCEPT SIGNATURE

User Name: ________________________________________________________ E-Mail: ________________________________________

Department: _______________________________________________________________________________________________________

Address: __________________________________________________________________________________________________________

City, State Zip code: ________________________________________________________________________________________________

Phone: ____________________________________________________ Fax: __________________________________________________

Application(s) for which Login is Requested: ___________________________________________________________________________

By signing below, I acknowledge that I may not disclose information about computer passwords and identification

characters. The login provided by my County Administrator is designated for my use when accessing online DLGF

applications and I am responsible for all activity under my login. If I become aware of any breach or suspected breach

of information security, I will promptly report it to my supervisor and the County Administrator. The County

Administrator should in turn report the matter to the DLGF. In addition, I acknowledge my responsibility to secure all

records that may contain confidential information from the view of or access by unauthorized persons. Confidential

paper files should be stored in locked cabinets or drawers whenever feasible, should not be left unattended in areas

where visitors may enter, and should be disposed of by shredding or other secure method. I understand that I may not

allow access to electronic files by unauthorized persons, nor to authorized persons for unauthorized purposes, and

that I must follow the electronic security measures for confidential and sensitive information that are established by my

supervisor.

Signature of User: ________________________________________________________ Date: __________________________________

County Administrator Use ONLY

County Administrator

Use ONLY

County Administrator

Use ONLY

USERID: __________________________________ Completed By______________________ Date Completed: ____________________

APPROPRIATE ACCESS PROVIDED: ________________________________________________________________________________

Online Application Login Request Form Online Application Login Request Form