Request Type Clause Samples

Request Type. Add access for new employee/third-party vendor Delete access for existing employee/third-party vendor Change access for existing employee/third-party vendor Name change for existing employee/third-party vendor Former name: I have read the provisions set forth on Page 2 of this form. I understand that Wisconsin Statutes, § 943.70 provide criminal penalties for offenses against computer data and programs. Violation of this provision will result in termination of my online access to member accounts and/or termination of my employer’s online access to member accounts. Employee name (first, middle, last) Vendor name (if applicable) Work address IAM login ID Check here if you do not currently have an IAM login Work email address Employee or vendor signature Work telephone ( ) Date (MM/DD/CCYY)

Request Type. This is a required field. Select one of the options available: Modify: This option allows you to make changes to enrolled Users you do not wish to remove, e.g. privileges, vaccinator status. Remove: This option allows you to inactive Users from VacTrAK. A User whose employment at your organization/facility has ended must be reported to VacTrAK within 3 business days. Name: This is a required field. Please provide the full name of staff members in your organization/facility that you wish to have access to VacTrAK. If there is no middle initial, enter N/A.

Request Type. New Agreement, Renewal Agreement, Update Agreement

Request Type. I am establishing a new Fidelity Advisor SIMPLE IRA Plan. (Complete all sections below in full.) I am requesting change(s) be made to my Employer information for the existing Fidelity Advisor SIMPLE IRA Plan. (Indicate the changes requested by checking the boxes below and completing the appropriate section with the new information.) * This change will constitute an amendment to your Plan.

Request Type. New Setup ☐ Cancellation ☐ Change of Information ☐ Request Date: _ mm/dd/yy