FACILITY E-MAIL ADDRESS
|Employee Information |Account Type: |
| |New account Modify account Transfer/Move account |
|Legal Name: |Phone Number: |Employee Number: |User Name: |
| | | | |
|Date (MM/DD/YYYY) | | | |
| | | | |
|Employee Type: |Job Classification: |Supervisor Name/User ID: |
|(Select one) | | |
|Contractor Employer Information: |
|Contractor’s Employer: |Contractor’s full address (City, State and Zip): |Contractor’s phone number: |
| | | |
|Work Location: |
|Work Location or Site name: |Location Address (include city state and zip code): |
| | |
| | |
|Building and Room Number: |Work phone number: |Work fax number: |
| | | |
|Agency Information: |
|Program Office/Deputate: |Bureau: |Facility Name or Division |
| | | |
|Section: |Unit: |Active Directory OU: |
| | | |
|Email Account Type: (Leave all email options blank for “NT only”) |
| Exchange Mailbox (basic email account) |
|Internet Email (Send and receive email from outside the Commonwealth) |
|Allow OWA Access (allows the user to check email using the internet) |
|Transferring From (Agency Name): |
|Additional account needs: |
|Internet Access: (Select one) |
|Roles and Group needed (List the role or group names here) : |
| |
Save the E-mail CWOPA Request Form and transmit via E-mail as an attachment to:
OISAccountAdministration@state.pa.us
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