Free Microsoft Word - VA9957.DOC - Federal

Department of Veterans Affairs

ACRS TIME SHARING REQUEST FORM

PRIVACY ACT STATEMENT: The information is solicited under authority of Title 38, United States Code and Executive Order 9397 and is necessary to accomplish the action requested by the requester, including establishing, modifying or deleting a Time Sharing Customer Account. Furnishing the information on this for, including your Social Security Number, is voluntary; however, if the information is not furnished, we will be unable to take further action on your request.
NOTE: Information from this form is used to establish a Time Sharing Account.
1. ACTION REQUESTED (Check only one of the three items) CREATE NEW CUSTOMER A. NAME MODIFY EXISTING CUSTOMER DELETE EXISTING CUSTOMER C. SOCIAL SECURITY NUMBER

2. CUSTOMER INFORMATION
B. TIME SHARING CUSTOMER ID

D. TELEPHONE NUMBER (Include Area Code)

E. FACILITY (STATION) NUMBER/SUFFIX

F. MAIL ROUTING SYMBOL OR STOP CODE

OGA
G. JOB TITLE H. SUBSYSTEM APPLICATION FUNCTION CODE (SAFC)

26D2
I. IF FOR CONTRACTOR, OR IF TEMPORARY ACCESS, SHOW EXPIRATION DATE (Month, day, year) J. EMPLOYER (For Contractor or Other Government Organization)

K. OFFICE ADDRESS (Street, City, State, Zip Code, for Contractor or Other Government Organization)

E-mail address:
NOTE: See reverse for instructions.
CHECK APPROPRIATE BOX ADD DELETE

Proxy Server/IP Address:
3. FUNCTIONAL TASKS
FUNCTIONAL TASK CODES CONCURRING SYSTEM MANAGER OF RECORD (SMR) DESIGNEE SIGNATURE & TITLE (If required)

1NARA85--MRS Record Order 1NARA86--MRS Look-up only

4. SIGNATURES
REQUESTING OFFICIAL & TITLE DATE

APPROVING OFFICIAL & TITLE

DATE

SECOND APPROVING OFFICIAL & TITLE (If required)

DATE

FACILITY POINT OF CONTACT

DATE

VA FORM JUL 1997(R)

9957