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Print Lotus Notes email short name (e.g. Jane Smith jsmith or j1smith) Org./Office Code: Telephone No. : Fax No.: I have read and signed Form 1264-3, Individual Computer User s Statement of Responsibility for the General Rules and Guidelines Governing the Use of BLM Computer Systems. My Form 1264-3 is on file with the State/Center IT Security Manager. Signature: Date:.

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