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Field Info: Proxy Request Form

Utility Software Services - Departmental Proxy Request Form
Please note: only a Dean, Director, or Department Head may authorize a departmental proxy.

This form should be completed by the "authorizing" individual for the proxy.

Dept Name: Dept#:
Authorized by: Date:
Authorized title:
Phone: Email:

Below, please list the proxy individual with one department number per line. (An individual will be listed more than once if he/she supports multiple departments.) You may list up to ten individuals to act as proxy for one department number.

** Please be sure to specify the desired action. **

Action:
Fully Qualified Name:
(Example:
veronica.j.smyth.0)
Purdue Domain Email:
(Example: vsmyth@purdue.edu)
Proxy Dept#:
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu
Add Remove @purdue.edu