Remote Access Request Form!

First Name* Last Name:
Email* Phone #:
Clinical Practice Site*
If other
If you would prefer to create your own password that is easier for you to remember, please enter it in the space below. It is the policy of Western University, Department of Information Technology that passwords for all University applications and network access must be a minimum of 6 characters in length, must contain at least one uppercase letter, one lowercase letter, one number and preferably should not be a dictionary word in any language. If you leave this field blank or do not use the above criteria to create your own password, a random password will be created for you.
Notice to users of electronic resources:

Access to electronic resources is governed by license agreements which restrict use to Western University of Health Sciences Authorized Users and to individuals who use Western University's facilities. Authorized users are Western University faculty, staff, currently enrolled students, and clinical faculty officially appointed through the University’s Academic Affairs office. It is the responsibility of each user to ensure that he or she uses these products only for individual, noncommercial use without systematically downloading, distributing, or retaining substantial portions of information. Violation of license agreements could result in the loss of remote access by the individual and possibly for the entire Western University community.

By checking this box, I acknowledge that I have read the notice above and understand that I must abide by the license restrictions. I also understand that the password I am issued will be valid until the end of the academic year (June 30) and that it can only be used for my individual, noncommercial use and may not be shared.
* Required