NEOMIN   Account Application	Add  Change  Delete	Please complete, print & include signatures Fax or mail to NEOMIN for processing 528 Educational Hwy, Warren OH 44484 FAX: 330 847-8568   PH: 330 847-6464 Click here for a plain text version of this form

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Name:	Work Phone Number/Ext.	E-mail:
Your job title:	Your district:	Your building:
Athletic Director Curriculum Director EMIS Coordinator Fiscal Personnel Food Services Guidance Counselor Librarian Maintenance Personnel Media Clerk NEOMIN Staff Principal Principal Assistant Secretary Student Service Personnel Superintendent Teacher Technology Personnel Transportation Personnel Treasurer Other	Ashtabula City Badger Bloomfield Bristol Brookfield Buckeye Champion Conneaut Geneva Girard Grand Valley Howland Hubbard Jefferson LaBrae Lakeview Liberty Lordstown Maplewood Mathews McDonald Newton Falls Niles Pymatuning Valley Southington Warren City Weathersfield Ashtabula JVS Ashtabula ESC Trumbull Career & Tech. Center Trumbull ESC NEOMIN Non Public	Lakeside HS Lakeside 9 Columbus Jr HS West Jr HS Chestnut Elem McKinsey Elem Plymouth Elem Saybrook Elem State Rd Elem Thurgood Marshall Elem Thomas Jefferson Elem Washington Elem BOE
Select services you need:
ESIS - See your district ESIS Coord	Fiscal Applications/Remote PO *	District Email Administration
Email - See your Technology Coord	EMIS State Data *	District Proxy Administration
Select distribution lists PERTINENT to your job :
Adult Education	Athletic Directors	Attendance Officers
Business Office	Curriculum Directors	EMIS Coordinators
Fiscal Services	GED Test Administrators	Guidance Counselors
INFOhio Users	Maintenance Personnel	MultiLIS/SIRSI Users
Non Public Schools	Principals	School Board Members
SchoolNet	Special Education	Student Services
Superintendents	Teachers	Technology Coordinators
Test Coordinators	Transportation Personnel	Vocational Education

* indicates you also need to fill out the EMIS/Fiscal authorization form

The NEOMIN systems to which your account has access should be used exclusively for district related business. It is understood that misuse of your account can lead to the temporary or permanent loss of system access. Any loss of data or costs resulting from the misuse of these privileges will be the responsibility of the school district or company requesting these privileges. NEOMIN reserves the right to reject requested privileges where sufficient need is not demonstrated as well as the right to suspend use of the account for reasons of misuse or for system maintenance. Please review the NEOMIN policies before signing this form. By signing this form you are stating that you have read & consent to the referenced NEOMIN policies & that you have signed an Acceptable Use Policy at the district level.
_______________________________________ Name Printed  (Job title if you chose "other" )		__________________________________________ Your Signature & Date
_______________________________________ Supervisor's Name Printed		__________________________________________ Supervisor's Signature & Date
_______________________________________ NEOMIN Executive Director		__________________________________________ Superintendent/Authorized Employee's Signature/Date