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e-Store
Dial-Up Access for Off-Campus Students Request Form
*All fields are required for form submittal.
Requested by :
SSN:
Street Address:
City:
State:
Zip:
Telephone:
(
)
Major:
Classification:
Freshman
Sophomore
Junior
Senior
Graduate
PC Manufacturer:
Operating System:
Windows 2000
Windows XP
Windows Vista
Macintosh OSX
Is Norton/Symantec Antivirus Installed?
Yes
No
Norton/Symantec subcription expiration date:
Modem Type:
Internal
External
Modem Speed/Baude Rate:
14.4 K
28.8 K
33.6 K
56.0 K
