Technology Services Group - Southern Regional

Authority to Extend Computer Access. [Grace Period]

This form is to be used to authorise Departmental/Faculty computer registration officers to extend computer network and Internet access for the nominated staff member.

The grace period cannot be extended beyond the 30-day period that commences on the end-date.

1. Personal Details

   Title Prof Dr Mr Mrs Miss Ms	First Name
   Middle Initial	Last name
   Contact number

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2. Employment Details.

   Staff ID Number  

   (Grace Periods are not available for Post Graduate Students)

   Room Number  

   Username (required)  

   Which school/department does this staff member belong to?

   ice MIMR Department of Medicine IHSR Nephrology Newborn Services Obs & Gyn Paediatrics PHIMR Southern Clinical School Surgery Unknown or Department not listed

   Reason for Extension

   Renewal of Contract still being negotiated.
   Renewal of Contract dependant upon a pending research grant.
   Other (Please specify)
   

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