The purpose of this form is to request access to networked computer system(s) in the Bon Secours Virginia Health Corporation.

Managers should fill out this form for the staff member requesting access to any application.

By filling out the form above, I verify that the above named person is an employee and has a legitimate need to access networked computer systems managed by the Information Services department of the Bon Secours Virginia Health System to fulfill their job responsibilities. I further agree that, if the individual is not an employee of Bon Secours Virginia Health System, I take full responsibility for any acts the individual performs on the networked computer systems.