Free Microsoft Word - VA9957 Instructions.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

Enter your name
D. TELEPHONE NUMBER (Include Area Code)

Leave this blank
E. FACILITY (STATION) NUMBER/SUFFIX

Enter your SSN
F. MAIL ROUTING SYMBOL OR STOP CODE

Enter your office telephone
G. JOB TITLE

OGA

AF users enter: 061 AR and Navy users enter: 062
H. SUBSYSTEM APPLICATION FUNCTION CODE (SAFC)

Enter your job title
I. IF FOR CONTRACTOR, OR IF TEMPORARY ACCESS, SHOW EXPIRATION DATE (Month, day, year)

26D2
J. EMPLOYER (For Contractor or Other Government Organization)

Leave this blank (unless a contractor)
Enter Your Office Address (Include Room Number and Office Symbol) E-mail address: Enter your e-mail address
NOTE: See reverse for instructions.
CHECK APPROPRIATE BOX ADD DELETE

Enter Army, Navy or Air Force
Proxy Server/IP Address: If you look up or order records, you must enter your Proxy server address here. Contact your System Administrator for the Proxy Server address through which your Internet traffic flows. If there is none at your MTF, enter the IP address of your worksite computer.)
3. FUNCTIONAL TASKS

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

FUNCTIONAL TASK CODES

CONCURRING SYSTEM MANAGER OF RECORD (SMR) DESIGNEE SIGNATURE & TITLE (If required)

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

Check the ADD box if the user is authorized to look up and to ORDER records from the MRS Check the ADD box if the user is only authorized to LOOK UP records on the MRS but may not submit record orders

Send the completed form to: National Personnel Records Center Attn: NRPS-Rademacher 9700 Page Ave., Room 2076 St. Louis, MO 63132
4. SIGNATURES
REQUESTING OFFICIAL & TITLE DATE

Obtain your boss's signature/title
APPROVING OFFICIAL & TITLE

Enter date
DATE

Obtain approving official's signature/title
SECOND APPROVING OFFICIAL & TITLE (If required) FACILITY POINT OF CONTACT

Enter date
DATE DATE

VA FORM JUL 1997(R)

9957