Office of Larry E. Reider
Kern County Superintendent of Schools
 Internet Account Request Form
Personal Information
NAME: __________________________________________________________________________________
Last                 First     Initial
SOCIAL SECURITY NUMBER: ________  ____  ________
 
ADDRESS: _______________________________________________________________________________
         Street City State                        Zip
PHONE:  ______-__________________ ______-__________________
              Work   Home  
EMPLOYER: _________________________________        _________________________________
            District Name          School Name/Department  

Account Information
VERIFICATION CODE: ______________________________
          (used for security purposes to verify that you are the user)
PLATFORM TO BE USED: (check one) ____Windows 95/98  ____Windows ME  ____Windows 2000/XP  ____Macintosh
 
SERVICE REQUESTED: (check one) ____E-mail only (no charge to school districts)
  ____Dial-up home access (monthly fee payable by Payroll deduction only)
SIGNATURE OF EMPLOYEE: _____________________________________________________
  By signing this request I am agreeing to abide by the policies at http://isp.kern.org/

DISTRICT AUTHORIZATION IS REQUIRED TO PROCESS THIS FORM.   DO NOT COMPLETE THE REMAINDER OF THIS FORM.

Account Approval (TO BE COMPLETED BY AUTHORIZED SITE REPRESENTATIVE)

Name_________________________________________________    Phone______________________

Title_____________________________________________________________________________

District_______________________ School/Department____________________________

Address____________________________________ City________________  Zip___________

Signature: ____________________________________

Return completed form to:
Office of Larry E. Reider, Kern County Superintendent of Schools
Technology Services, Attn: Kathy Freeman, 3rd Floor
1300 17th Street - CITY CENTRE
Bakersfield, CA 93301-4533   (661) 636-4559 FAX (661) 636-4020
TECHNOLOGY DEPT ONLY
______________ ______________ ______________ ______________
Date Received Date Entered Date Activated Date Deactivated