Neuro Information Technology
Computer Registration Request Form
Required for Network access to wired network.
(Not required for Wireless access)

* Denotes required entry
* First Name:
* Last Name:
* Department:
* Phone:
* Email Address:
Required Information
* Data Jack#:  
* Room#:  
* Computer Type:

  

* Make and Model Number:
* Status:

  

* MAC Address of Computer:
(Click here for instructions)

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