ANNEX A

REQUEST FOR SYSTEM ACCESS/ BIR Form No.

ACCESS REVOCATION
PRINT CLEARLY /PROVIDE COMPLETE INFORMATION
4044
Revised October 20 18
jser / Requester (Please Print)

l. Last Name 2. First Name 3. Middle Name

4. Office E srn n Non-BIR 5. Job Designation/Role 6. Log-in

ENo Dnn specifu office/ section/unit

l-l noc I-l nno

7, Signature 8, Contact Number/s (Telephone / Mobile) 9. BIR E-Mail Address 10. Date (rrm/dd/yyyy)

ll. Type ofRequest

A. SYSTEM ACCESS B. ACCESS REVOCATION
System

f] o.l" tion E srspensio,

E Leave ofAbsence <indicate period>

'n tr Speciat E Change ofOflice <indicate RTAO No.>

New Account tltf Resignation <indrcate eflectivity date>

n Replace Job Designation Retirement <indicate effectivity date>

n Add Job Designation E Others

tltl Reactivation of Suspended Account

Resetting oi Password
Special Instructions prior to Deletion of Account:
(APPLICABLE TO USERS WITH OS ACCESS ONLY)
n Extensron ofAccess

E
Validity of Special Access Request Move Files from User Home Directory To Directory

mm I dd /

Technical Users only

12. ITS Server Type: E Production E Testing
flcor f]vanita nqcv nnnz
13. Security Management Division ONLY
Euatati Evi'-vtin I I-ro
E Developrnent n Training

Remarks
T Existing Role(s)
Specifi role/s

E New Role/s

Implementation E ln-house Requirements Submitted E Acceptable Use Policy l--l

tl Outsource E Non-Disclosure Agreement E
Justificatiorr letter
oth..,
14. AT]THORIZING OFFICIAL
Head of Office (AC lDir./Div. Chief/R
Date (mm/dd/yyyy)

over Printed Name

I5. E\ALI ATED BY

Head, Revenue Data Center

16. VALIDATEDBY
l
ll
lm Date (mmldd/yyyy)

Chief, Security Management Division

Date (mm/dd/vvvv)
I Signature over Prrnted Name I

17. IMPLEMENTED BY f]System Administrator flDatabase Administrator

I I Date {mm/dd/vvvv)
l----_- lffi
I 5rBnature uYe r l'ruted l\antc