New User I.T. Request

New User I.T. Request

Please fill out and specify needs for new user
Name of Requester *
Person filling out form.
E-mail of Requester *
Cell Phone Number of New User (For DUO MFA) *

Area Code Phone Number
Name of New User *

First Name Last Name
Planned Start Date *

Month Day Year
Does the User need a SMV Email *
If email required, select all the distribution groups that apply to the new user.

Admin Office Admin Services ALH Trans ALH Notes Care Center Management Team Care Plan Team CC Work Order Request CHC Users Concierge Services Coordinators Daily Occ Reports Daily Status Users Death Notification Directors Executive Team Heath Care Service Management Homemaker Companion Services Hospital Report Managers Move Ins Operator Notes PO Complete PO Request Safety Committee Sales Security Report Termination Transportation Vacancy Report Vendors Village Health Wellness Committee None
Does the User need a Desk Phone? *
Department *
Type of Computer *
Choose Software to Install

Microsoft Office Adobe Acrobat Google Chrome Creative Cloud
Other Software
Peripherals Needed (Select all that Apply)

Wireless Mouse/Keyboard Printer Scanner 2nd Monitor Webcam Speakers
Additional Requirements

Remote Capabilities (VPN) Laptop Case
Konica Print/Copiers Requested

Admin Marketing HR Finance Rehab Highland Lakes
Mapped Share Drives/Folders Requested: *
iPads do not use this field
Additional Information
Date Submitted *

Month Day Year
Date Requested By *

Month Day Year
Should be Empty: