Va Form 9957 - Acrs Time Sharing Request Form printable pdf download

Va Form 9957 - Acrs Time Sharing Request Form

ACRS TIME SHARING REQUEST FORM

Department of Veterans Affairs

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 Time Sharing Customer Account. Furnishing the information on

this for, including your Social Security Number, 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 a Time Sharing Account.

1. ACTION REQUESTED (Check only one of the three items)

CREATE NEW CUSTOMER

MODIFY EXISTING CUSTOMER

DELETE EXISTING CUSTOMER

2. CUSTOMER INFORMATION

A. NAME

B. TIME SHARING CUSTOMER ID

C. SOCIAL SECURITY NUMBER

D. TELEPHONE NUMBER (Include Area Code)

E. FACILITY (STATION) NUMBER/SUFFIX

F. MAIL ROUTING SYMBOL OR STOP CODE

OGA

G. JOB TITLE

H. SUBSYSTEM APPLICATION FUNCTION CODE

(SAFC)

26D2

I. IF FOR CONTRACTOR, OR IF TEMPORARY ACCESS, SHOW EXPIRATION

J. EMPLOYER (For Contractor or Other Government Organization)

DATE (Month, day, year)

K. OFFICE ADDRESS (Street, City, State, Zip Code, for Contractor or Other Government Organization)

E-mail address:

Proxy Server/IP Address:

NOTE: See reverse for instructions.

3. FUNCTIONAL TASKS

CHECK

APPROPRIATE

CONCURRING SYSTEM MANAGER OF RECORD (SMR) DESIGNEE

FUNCTIONAL TASK CODES

BOX

SIGNATURE & TITLE (If required)

ADD

DELETE

1NARA85—MRS Record Order

1NARA86—MRS Look-up only

4. SIGNATURES

REQUESTING OFFICIAL & TITLE

DATE

APPROVING OFFICIAL & TITLE

DATE

SECOND APPROVING OFFICIAL & TITLE (If required)

DATE

FACILITY POINT OF CONTACT

DATE

VA FORM

9957

JUL 1997(R)

Va Form 9957 - Acrs Time Sharing Request Form

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