Form Deactivated IT Access FM-PRN-044

USER INDENTITY

Name / ID / NIK Phone / Hand phone

Unit Kerja E-mail

Status Permanent Employee / No. and Date (for
Contract & Work
Contract / Work Partners
Partners)
Position Address

DISABLING/ REVISE ACCOUNT

Access Type:

O/S ............... Aplikasi ................ Database Akses Network Email

Segmentasi User :

Administrator Director GM Manager User

Phase of use :

Development.................. Production .................... Training........... ........................................

Starting Deactivate Date :

APPROVAL
User Request Name: Sign : Date :

Head of User / Atasan Name : Sign : Date :

Pemohon

Admin Name : Sing : Date :

Reason :