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 :