Neuro Information Technology Application/Renewal
for McGill Username Credentials Form

For non-McGill staff working in association with
McGill who need to access McGill IT Services
You may request a McGill Email mailbox or continue to use an external email address.

Effective August 1, 2014, McGill University will no longer issue McGill IT Affiliate accounts to MUHC hospital staff or NON-McGill staff unless they are working in conjunction with a McGill Department where they are required to access McGill Services as part of their working environment. McGill IT affiliate accounts will not be issued just for Wi-Fi or Wireless access unless it is required to perform work related functions in relation to a McGill Department or Faculty.

Access is enabled for a maximum of 1 year, renewable annually by submitting an updated form. For assistance contact the ICS Service Desk online at http://kb.mcgill.ca/it/servicedesk or by phone at 514-398-3398. For information on your McGill Username go to http://kb.mcgill.ca/it/mcgillusername.
* Denotes required entry
Please select whether this is a renewal or a new application.
*
Applicant: * First Name:
  * Last Name:
  * Date of Birth1 Gender:   
                                         (yyyy/mm/dd)
Former McGill Staff or Student?

If Yes: (optional)
 McGill ID#  Year
Employer:
* Name of Hospital 2 or non-McGill unit:
  
"
* Department:
"
* Hospital ID# (REQUIRED)
Telephone: * Office: ( )
"
* Home:( )
McGill Username (for renewals only):  
Current email address: *
Email mailbox needed?
*
(firstname.lastname@mail.mcgill.ca)
        (Yahoo, Gmail, etc.):

* I have read and agree to abide by the Policy on the Responsible Use of McGill Information Technology Resources, found on the Secretariat website at www.mcgill.ca/secretariat/policies/informationtechnology/.

1 Date of birth and gender are used solely to distinguish between people with the same name.
2 For Montreal Neurological Hospital staff ONLY

* For security reasons, please enter the characters
from the image below into the text box :