New Search
Access Request Form Page 1 of 1 <br /> GAPS PRODUCTION SYSTEM <br /> EXTERNAL USER ACCESS REQUEST FORM <br /> ORGANIZATION NAME A .41 e4'Th <br /> SECTION I: DUNS No. 10_104-6 (03� T IDNo. q -( _I(00- <br /> SECTION II: USER IDENTIFICATION <br /> User Name: 4Q t d ev Io (i m • <br /> (Last ] (First) (MI) <br /> User Signatu 1 _ �� , , <br /> Telephone #: (4) (DT a -gor1 Date of Birth: q - 17- rib <br /> Internet Address: KY (, o m o hcci� an 6, o e Pie , Die, (LS <br /> (Official address for E elbctronic correspondence).) <br /> Individual Email: N It e en. Ir(a( ,(dell Q� 0), o e�le Cr. (,LS <br /> ( 54-4-- <br /> Individual Social Security Number: - c -- - <br /> (Furnishing the Social Security Number information on this form is voluntary, but failure to do so may <br /> result in denied access to GAPS) <br /> Is this user a Servicer? [ ] YES X NO (Mark only one with an "X ") <br /> If you checked "YES" above for a Servicer, please give the Servicer address otherwise provide <br /> the Organization address below. <br /> Address: t?'�� a/e - t <br /> r i - <br /> OR_ 1 4 - O -- <br /> Ital — @ T . ` J ` h F t j)/t o <br /> SECTION III: GAPS ACCESS `)91401) <br /> )(Full [ ] View Only (Mark only one with an "X ") <br /> SECTION IV: USER ACKNOWLEDGMENT AND ACCEPTANCE OF RESPONSIBILITIES: <br /> a. Know the sensitivity of the information processed in GAPS which is financially sensitive and privacy sensitive. <br /> b. Protect sensitive information from access by, c.. disclosure to unauthorized personnel. <br /> c. Create and use a combination • ' 1phan ri.. character p. ords and not disclose your password to anyone. <br /> SECTION V: AUTH <br /> Authorized by: , /,_ Title: ilk 4/4„.1;-(4).(4„ 1 {G` <br /> Signature: ;// Date: S /'G? Telephone #: Sy " 6'S? ye/ <br /> (10/17/00) <br /> http: / /e- grants. ed. gov/ gapsweb/ download/externalaccessform.htm 5/31/2002 <br />