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 CodePhone Number
Name of New User*

First NameLast Name
Planned Start Date*

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

Admin OfficeAdmin ServicesALH TransALH NotesCare Center Management TeamCare Plan TeamCC Work Order RequestCHC UsersConcierge ServicesCoordinatorsDaily Occ ReportsDaily Status UsersDeath NotificationDirectorsExecutive TeamHeath Care Service ManagementHomemaker Companion ServicesHospital ReportManagersMove InsOperator NotesPO CompletePO RequestSafety CommitteeSalesSecurity ReportTerminationTransportationVacancy ReportVendorsVillage HealthWellness CommitteeNone
Does the User need a Desk Phone?*
Department*
Type of Computer*
Choose Software to Install

Microsoft OfficeAdobe AcrobatGoogle ChromeCreative Cloud
Other Software
Peripherals Needed (Select all that Apply)

Wireless Mouse/KeyboardPrinterScanner2nd MonitorWebcamSpeakers
Additional Requirements

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

AdminMarketingHRFinanceRehabHighland Lakes
Mapped Share Drives/Folders Requested:*
iPads do not use this field
Additional Information
Date Submitted*

MonthDayYear
Date Requested By*

MonthDayYear
Should be Empty: