Please print out and complete this form, than fax it to 780-4933 or mail to
Telecommunications Department (4 Payson Smith Hall).

---

University of Southern Maine
Authorization Code Form
New authorization codes must be issued if there is a change in account numbers.

---

Department: _________________________________________________________________________


Contact Person: ________________________________________ Phone: ________________________

*PeopleSoft  Chart Fields

Dept. ID #	Acct #	Fund #	Program/Project #
___│___│___│___│___│___│ ___	6│ 4│ 0│ 0│8	___│___	__│___│___│___│___│___│ ___

---

Authorization Code:

● ADD* ____     ● DELETE* ____

*Please submit a separate form for each request.

Name: ____________________________________________	Ext. #___│___│___│___│
Address (Bldg, Campus etc.): ________________________________________________________
Address: _________________________________________________________________________

---

Authorized by: _______________________________     Signature: ___________________________

Date: ___│___│___

rev 8/06

---