FND-136
Security Authority for WBSCM Users
User Type
*
Please Select
Recipient Agency
Education Service Center
Internal TDA
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Recipient Agency (RA) Information
Organization Name
*
Business Street Address
*
City
*
State
Zip
*
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Education Service Center
Region
*
Please Select
Region 1: 1900 West Schunior Edinburg, TX 78541
Region 2: 209 North Water Street Corpus Christi, TX 78401
Region 3: 1905 Leary Lane Victoria, TX 77901
Region 4: 7145 West Tidwell Houston, TX 77092
Region 5: 350 Pine Street, Suite 500 Beaumont, TX 77701
Region 6: 3332 Montgomery Road Huntsville, TX 77340
Region 7: 1909 N. Longview Street Kilgore, TX 75662
Region 8: 4845 U.S. Highway 271 N. Pittsburg, TX 75686
Region 9: 301 Loop 11 Wichita Falls, TX 76306
Region 10: 400 E. Spring Valley Road Richardson, TX. 75081
Region 11: 1451 S. Cherry Lane White Settlement, TX 76108
Region 12: 2101 W. Loop 340, 76712
Region 13: 5701 Springdale Road Austin, TX 78723
Region 14: 1850 Highway 351 Abilene, TX 79601
Region 15: 612 South Irene Street, 76903
Region 16: 5800 Bell Street Amarillo, TX 79109
Region 17: 1111 West Loop 289 Lubbock, TX 79416
Region 18: 2811 LaForce Blvd., 79706
Region 19: 6611 Boeing Drive, 79925
Region 20: 1314 Hines Avenue San Antonio, TX 78208
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User Information
User Name
*
Legal First Name (no nicknames authorized)
Legal Last Name
User Position Title
*
User Phone Number
*
Please enter a valid phone number.
User Business Email
*
Approver Information
For RA, information should be of the Highest Official of your entity such as Superintendent, President of the Board, etc.
Approver Name
*
Legal First Name
Legal Last Name
Approver Business Email
*
Confirmation Email
Enter the email address again to verify
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Access Request
RA Request
*
Please Select
Add New RA User Administrator
Remove Existing RA User Administrator
ESC Request
*
Please Select
Add New View Only-SDA/ITO user
Remove Existing View Only-SDA/ITO user
TDA Add
View-Only – SDA/ITO
Recall Specialist – SDA/ITO
Recall Contact – SDA/ITO
Complaint Specialist – SDA/ITO
Order Manager – SDA/ITO
Org Admin – SDA/ITO
User Admin – SDA/ITO
TDA Remove
View-Only – SDA/ITO
Recall Specialist – SDA/ITO
Recall Contact – SDA/ITO
Complaint Specialist – SDA/ITO
Order Manager – SDA/ITO
Org Admin – SDA/ITO
User Admin – SDA/ITO
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User Signature
Signature
*
Date
*
-
Month
-
Day
Year
Date
DateTime
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Submit for Approval
Geo Information
Submit
Submit
Should be Empty: