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Access to Campus Services Request Form
for Media Giraffe Project conference registrants, June 28-July 1, 2006

The University of Massachusetts Office of Information Technologies (OIT) will provide temporary access to the campus Internet wireless and wired networks for registered attendees of the Media Giraffe Project summit conference. There is no extra charge. However, to gain access to the campus network, you MUST complete this form and, email, fax or mail it to be received by Shelley Gibbons, conference registrar, not later than June 23. Your temporary user name and password will be given to you at arrival registration on campus. If you have questions about this form please call Shelley Gibbons at 413-545-0172.

WHAT TO DO WITH COMPLETED FORM:

You should (a) complete this form as a Microsoft Word document and return it to sgibbons@mail.aux.umass.edu or (b) FAX it to: Shelley Gibbons, UMass Conference Services, at (413) 545-0050 or (c) mail it to: University Conference Services / Attn. Shelley Gibbons / 918 Campus Center / Univ. of Mass. / Amherst MA 01003-9272.

Date faxed/mailed: _________________________________

Required Information

Last Name ___________________________________________________________

First Name Middle Initial

For unique identifier:
If US ... Social Security Number (optional) ______________________________________ ________

OR Driver.s License: STATE __________ Number: ____________________________________________________

If Non-US, Visa or Passport Number________________________________________ Nation: ______________________

Gender ____ Male ___ Female Date of Birth: ________________________

	Home/Permanent
Address 1
Address 2
City
State
Postal Code
Home phone:	( )
Email
	Amherst-area location
___ drive in	___ Conf dorm / _____ CC Hotel / Other:
Cell phone (if any):