MSSIT Clients - Remove Access / User

Please complete the following form to notify MSS IT staff that an agency staff member should be disabled and/or removed.

Name Name First Last
Date of Separation/Termination Date of Separation/Termination / MM / DD YYYY
Requestor Information

Please provide all information for the person making the request.
Nonprofit Agency Name
Your Name
Your Title
Your Email
Any circumstances or information that MSS should know?