Premium Exchange Account for Student Use

Please complete the form and give to your ITS CSS Contact for approval and submission.

Note: Students must have a Windows Network Account. Managers must be employees of the University in the Department specified below. The annual fee is $75 and will be prorated the first year.

Department:

Account number to be billed**:

Authorized Signature**:

Manager Information

Last Name:	First Name:
NetID:

Student to be Granted Access:

Last Name:

First Name:

AlbanyID:

NetID:

ITS CSS Contact Signature:

ITS CSS Contact Printed Name:

ITS CSS Contact Phone:

Date:

**Account number and signature from an authorized signatory is mandatory.

Fax To:  CSS Accounts and Access Office, 442-3847