+----------------------------+-----+---+---+---+----+----------+-------+
| Federal Deposit Insurance  |     |   |   | * |    |          |       |
| Corporation                |     |   |   | C |    |          |       |
|                            |     |   |   | h |    |          |       |
| **NEW, TRANSFER, OR        |     |   |   | e |    |          |       |
| DETAILED USER**            |     |   |   | c |    |          |       |
|                            |     |   |   | k |    |          |       |
| **ACCESS AUTHORIZATION**   |     |   |   | o |    |          |       |
|                            |     |   |   | n |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | o |    |          |       |
|                            |     |   |   | n |    |          |       |
|                            |     |   |   | l |    |          |       |
|                            |     |   |   | y |    |          |       |
|                            |     |   |   | * |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
|                            |     |   |   | N |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | w |    |          |       |
|                            |     |   |   | U |    |          |       |
|                            |     |   |   | s |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | r |    |          |       |
|                            |     |   |   | E |    |          |       |
|                            |     |   |   | n |    |          |       |
|                            |     |   |   | d |    |          |       |
|                            |     |   |   | D |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | t |    |          |       |
|                            |     |   |   | a |    |          |       |
|                            |     |   |   | i |    |          |       |
|                            |     |   |   | l |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   | N |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | w |    |          |       |
|                            |     |   |   | D |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | t |    |          |       |
|                            |     |   |   | a |    |          |       |
|                            |     |   |   | i |    |          |       |
|                            |     |   |   | l |    |          |       |
|                            |     |   |   | T |    |          |       |
|                            |     |   |   | r |    |          |       |
|                            |     |   |   | a |    |          |       |
|                            |     |   |   | n |    |          |       |
|                            |     |   |   | s |    |          |       |
|                            |     |   |   | f |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | r |    |          |       |
|                            |     |   |   | S |    |          |       |
|                            |     |   |   | e |    |          |       |
|                            |     |   |   | p |    |          |       |
|                            |     |   |   | a |    |          |       |
|                            |     |   |   | r |    |          |       |
|                            |     |   |   | a |    |          |       |
|                            |     |   |   | t |    |          |       |
|                            |     |   |   | i |    |          |       |
|                            |     |   |   | n |    |          |       |
|                            |     |   |   | g |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| **INSTRUCTIONS**: Complete |     |   |   |   |    |          |       |
| a separate request for     |     |   |   |   |    |          |       |
| each employee. If this     |     |   |   |   |    |          |       |
| request contains a Social  |     |   |   |   |    |          |       |
| Security Number, send      |     |   |   |   |    |          |       |
| encrypted and digitally    |     |   |   |   |    |          |       |
| signed E-mail to Access    |     |   |   |   |    |          |       |
| Control.                   |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| **SECTION I - EMPLOYMENT   |     |   |   |   |    |          |       |
| STATUS** *(Check one       |     |   |   |   |    |          |       |
| only)*                     |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| > Permanent Intern Term    |     |   |   |   |    |          |       |
| > Contractor *(go to       |     |   |   |   |    |          |       |
| > Section III)*            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| **SECTION II - EMPLOYEE    |     |   |   |   |    |          |       |
| INFORMATION**              |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| NAME OF EMPLOYEE *(Last,   | D   |   | S |   |    |          | GRADE |
| First, MI)*                | ATE |   | O |   |    |          |       |
|                            | OF  |   | C |   |    |          |       |
|                            | BI  |   | I |   |    |          |       |
|                            | RTH |   | A |   |    |          |       |
|                            |     |   | L |   |    |          |       |
|                            |     |   | S |   |    |          |       |
|                            |     |   | E |   |    |          |       |
|                            |     |   | C |   |    |          |       |
|                            |     |   | U |   |    |          |       |
|                            |     |   | R |   |    |          |       |
|                            |     |   | I |   |    |          |       |
|                            |     |   | T |   |    |          |       |
|                            |     |   | Y |   |    |          |       |
|                            |     |   | N |   |    |          |       |
|                            |     |   | U |   |    |          |       |
|                            |     |   | M |   |    |          |       |
|                            |     |   | B |   |    |          |       |
|                            |     |   | E |   |    |          |       |
|                            |     |   | R |   |    |          |       |
|                            |     |   | * |   |    |          |       |
|                            |     |   | ( |   |    |          |       |
|                            |     |   | L |   |    |          |       |
|                            |     |   | a |   |    |          |       |
|                            |     |   | s |   |    |          |       |
|                            |     |   | t |   |    |          |       |
|                            |     |   | 4 |   |    |          |       |
|                            |     |   | - |   |    |          |       |
|                            |     |   | d |   |    |          |       |
|                            |     |   | i |   |    |          |       |
|                            |     |   | g |   |    |          |       |
|                            |     |   | i |   |    |          |       |
|                            |     |   | t |   |    |          |       |
|                            |     |   | s |   |    |          |       |
|                            |     |   | ) |   |    |          |       |
|                            |     |   | * |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| JOB TITLE                  | ORG |   |   |   | D  |          |       |
|                            | ANI |   |   |   | IV |          |       |
|                            | ZAT |   |   |   | IS |          |       |
|                            | ION |   |   |   | IO |          |       |
|                            | C   |   |   |   | N/ |          |       |
|                            | ODE |   |   |   | OF |          |       |
|                            |     |   |   |   | FI |          |       |
|                            |     |   |   |   | CE |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| NAME OF SUPERVISOR         | ST  |   |   |   |    | END DATE |       |
|                            | ART |   |   |   |    | *(mm/d   |       |
|                            | D   |   |   |   |    | d/yyyy)* |       |
|                            | ATE |   |   |   |    |          |       |
|                            | *(  |   |   |   |    |          |       |
|                            | mm/ |   |   |   |    |          |       |
|                            | dd/ |   |   |   |    |          |       |
|                            | yyy |   |   |   |    |          |       |
|                            | y)* |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| **SECTION III - CONTRACTOR |     |   |   |   |    |          |       |
| INFORMATION**              |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| NAME OF CONTRACTOR *(Last, |     |   |   |   |    | DATE OF  |       |
| First, MI)*                |     |   |   |   |    | BIRTH    |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| DIVISION/OFFICE            | ST  |   |   |   |    | END DATE |       |
|                            | ART |   |   |   |    | *(mm/d   |       |
|                            | D   |   |   |   |    | d/yyyy)* |       |
|                            | ATE |   |   |   |    |          |       |
|                            | *(  |   |   |   |    |          |       |
|                            | mm/ |   |   |   |    |          |       |
|                            | dd/ |   |   |   |    |          |       |
|                            | yyy |   |   |   |    |          |       |
|                            | y)* |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| NAME OF OVERSIGHT MANAGER  |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| NAME OF COMPANY            |     |   |   |   |    | T        |       |
|                            |     |   |   |   |    | ELEPHONE |       |
|                            |     |   |   |   |    | NUMBER   |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    | (        |       |
|                            |     |   |   |   |    |   )      |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| COMPANY ADDRESS *(Include  |     |   |   |   |    |          |       |
| City, State, and ZIP       |     |   |   |   |    |          |       |
| Code)*                     |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| 20\. WORK LOCATION         |     | 2 |   |   |    |          |       |
|                            |     | 1 |   |   |    |          |       |
|                            |     | \ |   |   |    |          |       |
|                            |     | . |   |   |    |          |       |
|                            |     | C |   |   |    |          |       |
|                            |     | O |   |   |    |          |       |
|                            |     | N |   |   |    |          |       |
|                            |     | T |   |   |    |          |       |
|                            |     | R |   |   |    |          |       |
|                            |     | A |   |   |    |          |       |
|                            |     | C |   |   |    |          |       |
|                            |     | T |   |   |    |          |       |
|                            |     | N |   |   |    |          |       |
|                            |     | U |   |   |    |          |       |
|                            |     | M |   |   |    |          |       |
|                            |     | B |   |   |    |          |       |
|                            |     | E |   |   |    |          |       |
|                            |     | R |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| OFF-SITE ON-SITE           |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
|                            |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+
| **SECTION IV - NETWORK     |     |   |   |   |    |          |       |
| ACCESS REQUIREMENTS**      |     |   |   |   |    |          |       |
| *(List the specific NT     |     |   |   |   |    |          |       |
| Group(s)/Folder(s) for     |     |   |   |   |    |          |       |
| which the above individual |     |   |   |   |    |          |       |
| require(s) access.)*       |     |   |   |   |    |          |       |
+----------------------------+-----+---+---+---+----+----------+-------+

  -----------------------------------------------------------------------
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  to insert another row. Otherwise, move the mouse to the next field.

  -----------------------------------------------------------------------

+-----------------------------------------------------------------------+
| **SECTION V - TELEPHONE REQUIREMENTS**                                |
+-----------------------------------------------------------------------+
| **NEW INSTALLATION**:                                                 |
|                                                                       |
| Telephone Number:[     ]{.underline}.*(If a telephone number          |
| currently exists in the office, enter the extension number in the     |
| space provided at left. Leave blank if there is not an existing       |
| telephone number.)*                                                   |
|                                                                       |
| Call Coverage *(Check one)*                                           |
|                                                                       |
| Point 1 Extension Number:[     ]{.underline}                          |
|                                                                       |
| Point 2 Extension Number:[     ]{.underline}                          |
|                                                                       |
| Point 3 Extension Number:[     .]{.underline}*(Not applicable if      |
| field office user.)*                                                  |
|                                                                       |
| *(**Note:** Voice Mail must be the last point of coverage.)*          |
|                                                                       |
| Does user need a Calling Card? Yes No *(If yes, enter range privilege |
| in the space provided below.)*                                        |
|                                                                       |
| Range Privilege: [     ]{.underline}.1 - FDIC Office Only             |
|                                                                       |
| 2 - United States                                                     |
|                                                                       |
| 3 - Worldwide excluding high fraud countries                          |
|                                                                       |
| 4 - United States/Canada/Puerto Rico/US Virgin Islands/Guam/Northern  |
| Mariana Islands                                                       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **SECTION V - TELEPHONE REQUIREMENTS** *(Cont'd)*                     |
+-----------------------------------------------------------------------+
| Does user need a Long Distance Authorization Code? Yes No *(If yes,   |
| enter range privilege in the space below.)*                           |
|                                                                       |
| Range Privilege:[     ]{.underline}. 1 - FDIC Office Only             |
|                                                                       |
| 2 - United States                                                     |
|                                                                       |
| 3 - Worldwide excluding high fraud countries                          |
|                                                                       |
| 4 - United States/Canada/Puerto Rico/US Virgin Islands/Guam/Northern  |
| Mariana Islands                                                       |
|                                                                       |
| **MOVE/CHANGE**:                                                      |
|                                                                       |
| Extension Number:[     ]{.underline}                                  |
|                                                                       |
| From: *(Building/Room)* [     ]{.underline}. To: *(Building/Room)*    |
| [     .]{.underline}                                                  |
|                                                                       |
| **DISCONNECT/DELETION:**                                              |
|                                                                       |
| Name:[     ]{.underline}                                              |
|                                                                       |
| Extension Number:[     ]{.underline}                                  |
|                                                                       |
| Room Number:[     ]{.underline}                                       |
|                                                                       |
| Building Address:[     ]{.underline}                                  |
+-----------------------------------------------------------------------+
| **SECTION VI - ADDITIONAL REQUIREMENTS/HARDWARE** *(Specify what      |
| additional requirements/hardware is needed in the space below.)*      |
+-----------------------------------------------------------------------+

  -----------------------------------------------------------------------
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  to insert another row.

  -----------------------------------------------------------------------

  ---------------------------- ---------------------------- -------------
                                                            

  **SECTION VII -- APPROVAL                                 
  AUTHORIZATION**                                           

  NAME OF AUTHORIZING OFFICAL  SIGNATURE OF AUTHORIZING     DATE
  *(Print or type)*            OFFICIAL                     

                                                            **     **

  **PRIVACY ACT STATEMENT**                                 

  12 U.S.C. § 1819 and                                      
  Executive Order 9397                                      
  authorize the collection of                               
  this information. This                                    
  information will be used by                               
  the FDIC to track the                                     
  assignment and maintenance                                
  of automated database user                                
  logon identification numbers                              
  and electronic access                                     
  necessary for the employee                                
  to perform assigned job                                   
  functions. Information in                                 
  this system may be disclosed                              
  to: appropriate Federal,                                  
  state, and local agencies                                 
  for law enforcement                                       
  purposes; the Merit Systems                               
  Protection Board; an                                      
  arbitrator; the Federal                                   
  Labor Relations Authority;                                
  the U.S. Equal Employment                                 
  Opportunity Commission; a                                 
  Congressional office in                                   
  response to an inquiry made                               
  at the individual's request;                              
  and in accord with other                                  
  routine uses of records                                   
  contained in the Unofficial                               
  Personnel System, \#                                      
  30-64-0015. Furnishing the                                
  information is voluntary;                                 
  failure, however, to furnish                              
  all of the requested                                      
  information may result in                                 
  the denial of access to some                              
  or all automated databases.                               
  If the FDIC denies such                                   
  access, you may be unable to                              
  perform some or all of your                               
  assigned job functions and                                
  your employment could be                                  
  adversely affected.                                       
  ---------------------------- ---------------------------- -------------