LDAP Members Area Userid Request Form

By submitting this CalConnect Userid Request Form, I confirm that:
  • I am an employee, officer, or authorized volunteer of a CalConnect member organization. 
  • I am requesting this userid with the approval of my organization's primary representative.
  • Granting this userid will establish me as a CalConnect Member Representative.
  • My organization has agreed to the CalConnect Membership Agreement.
  • I will comply with that agreement and with the CalConnect Code of Conduct.
First Name:
Last Name:
Address:
City:
State:
Two Letter ISO 3166 Country Code:
Zip: Cell Phone:
Work Phone: userid:
E-Mail:
Organization:
Fields labeled in Red are required. The combination of first and last name, and the userid fields must be unique in the database. If they have already been used, you will be instructed to press the "back" button on your browser to return to this page to enter new values until unique values for both "firstname lastname" and "userid" have been entered.
E-mail is required so we can return the information about your new ID to you.
Organization is the name of the Member organization of the consortium which you represent.