Name  _____________________________________________________ Email:_____________________________

SSN/SID#  _______________________     Phone #: ___________________________________________________

Mail Address ___________________________________________________________________________________

Check one:  ___ Faculty        ___ Student in CS Dept.      ___  Student in other majors at Virginia Tech

Department_________________________      CS Courses which you currently enroll  _____________________________

Check one:   ___  Open a new user account.  Choose one of  the following account types:
                                    ___  Permanent    ( only for faculty)
                                    ___  Regular  (student in CS Dept.)
                                    ___  Temporary (non CS major student)

                      ___  Extend an existing user account.     The account is ________________________________________
                                    ___   Regular (student in CS Dept.)
                                    ___  Temporary (non CS major student)

Desired username_____________________ (3 - 8 characters)

Initial password_______________________(change on first login, at least 7 characters which contain at least 1 number, uppercase or special characters)

Your signature is your statement that you fully understand and agree to abide by the rules as stated in the Appropriate Use of Computer Science Systems at Virginia Tech(http://www.cslab.vt.edu/policy.html).

Applicant Signature:   ____________________________________________________      Date:   ______________
 

CS Faculty Signature: ____________________________________________________      Date:__________________

CS Dept. Representative Signature: __________________________________________     Date: _________________

Operator Signature: ______________________________________________________     Date: _________________