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Patriot pass Request for Access to Patriot Web Items marked with are required. NAME First Middle Last Suffix CURRENT ADDRESS Street Apt. City State ZIP FORMER/MAIDEN NAME FACULTY/STAFF/STUDENT ID G NUMBER OR SSN DATE OF BIRTH // note date of birth is required if Faculty/Staff/Student ID is not provided DATE OR TERM YOU LAST ATTENDED/WORKED AT MASON CURRENT E-MAIL ADDRESS note if an e-mail address is provided you will be notified via e-mail of how to access your account. patriot pass Request for Access to Patriot Web Items marked with are required* NAME First Middle Last Suffix CURRENT ADDRESS Street Apt. City State ZIP FORMER/MAIDEN NAME FACULTY/STAFF/STUDENT ID G NUMBER OR SSN DATE OF BIRTH // note date of birth is required if Faculty/Staff/Student ID is not provided DATE OR TERM YOU LAST ATTENDED/WORKED AT MASON CURRENT E-MAIL ADDRESS note if an e-mail address is provided you will be notified via e-mail of how to access your account. DAYTIME PHONE PLEASE CREATE ENTER A SIX DIGIT CLAIM CODE HERE note this code may be any six numbers of your choice you will use it later as a temporary access for your account. I acknowledge and understand that by signing this document I am the person I claim to be and agree that all information submitted within is correct and accurate. In addition I acknowledge and understand that I am required to comply with all applicable federal state and George Mason University policies procedures and regulations regarding the use of George Mason University computing systems. Failure to comply with such policies procedures and regulations may result in a loss of access to computing resources and George Mason University may seek legal remedies. Furthermore I agree that I will only access those data that are related specifically to my personal records and that I will not share or disclose my account with others. I CERTIFY THAT I HAVE READ THE ABOVE AND AGREE TO IT. SIGNATURE DATE Note Students who have requested their records be coded Private must mail in a notarized access request original only or make their request in person with a photo ID. A faxed request is not acceptable. MAIL/FAX THIS FORM WITH A COPY OF YOUR PHOTO ID MASON ID DRIVERS LICENSE OR PASSPORT TO Please retain a copy of this form for your records. Print Form ITU Support Center George Mason University 4400 University Drive MSN 5D5 Fairfax VA 22030 Fax 703 993-3347. City State ZIP FORMER/MAIDEN NAME FACULTY/STAFF/STUDENT ID G NUMBER OR SSN DATE OF BIRTH // note date of birth is required if Faculty/Staff/Student ID is not provided DATE OR TERM YOU LAST ATTENDED/WORKED AT MASON CURRENT E-MAIL ADDRESS note if an e-mail address is provided you will be notified via e-mail of how to access your account. DAYTIME PHONE PLEASE CREATE ENTER A SIX DIGIT CLAIM CODE HERE note this code may be any six numbers of your choice you will use it later as a temporary access for your account. DAYTIME PHONE PLEASE CREATE ENTER A SIX DIGIT CLAIM CODE HERE note this code may be any six numbers of your choice you will use it later as a temporary access for your account. I acknowledge and understand that by signing this document I am the person I claim to be and agree that all information submitted within is correct and accurate.