NU Slate Access Request Form (Graduate)

Personal Information

First Name

Last Name

Preferred Name

Northeastern Email Address

Primary Phone

Job Title

myNortheastern Username

Manager Details

Manager First Name

Manager Last Name

Manager Job Title

Access Request

Are you a new user requesting access for the first time or are you an existing user requesting modifications to your access?

College / Access Group

Other Access Group:

Department

Grad Admissions Role

Which Program or Programs will you be reviewing applications for?

Please specify the type of access you need

Special Access Requested

Mirror system access of:

User Agreement

Northeastern University systems are to be used according to the terms of the University's Appropriate Use Policy.

I further agree to: access, distribute and share data, including test data, only as needed to conduct University business as specified in my position/engagement description, respect the confidentiality and privacy of individuals whose records or data I access, observing all ethical and legal restrictions that may apply, protect and be personally accountable for all work performed under my user id(s) and password(s), logout when leaving my workstation, report knowledge of security breaches to the University Data Administrator, and comply with all department and University security policies and procedures.

NOTICE: This application is not an employment contract in any form, although adherence to these standards is a condition of employment or continued role. Access granted pursuant to this application does not give rights of any kind, and may be changed by Northeastern University without notice at any time.

I have read and will abide by the above agreement and the Appropriate Use Policy. Under these terms, I request access to systems to be established according to the specifications on provisioning sheets attached to this application.

Signature