* NAME (last, first, middle initial)  

* SEX    Male

               Female                                

* BIRTH DATE     

* Social Security Number        

    (Contact Human Resources, 144 Graff Main Hall, 785-8013, if a temporary social security # is needed.)

   UW-L ID#  (If known)

* Local address        

* Phone

* Department/Unit

* Account Code 

* Employee's campus address:  (room & building)         

* Phone

* Supervisor

Time period access needed for:

* Start date     * End date

* Will this person be paid by UW-L?   Yes     No

* Services Needed/Access To:

    ID Card will provide access to:

           Murphy Library
           Computer labs
           Science labs
           Classrooms
           Exercise and recreation facilities

     E-Mail will provide access to:

           Murphy Library
           Computer log on

    Check here if the individual already has a student e-mail account.

     Other 

For on-campus parking, individual must contact the Parking Office directly at 785-8061.

Contact Payroll Services (144 Graff Main Hall, 785-8603) if applicable