Created: 4/14/2015
Request For CombIS User Account Information Sheet
(For Agency User Access)	
This Information Sheet is to be completed by Agency employees who want to access CombIS. The completed and signed form is to be submitted to CountyCulvertInsp@dot.nj.gov as an e-mail attachment with the subject “CombIS: Agency User Account” or delivered to the bureau of Structural Evaluation & Bridge Management.	
Agency’s Unit / Department / Bureau*:	     		
Person Authorizing Request* (Bureau Manager or Above):		
Name:	     	Title:	     		
Signature:	     	Date:	     		
	
Please CREATE New CombIS User Account for:	
First Name*:	     	Last Name*:	     		
E-mail*:	     		
	
Address 1:	     		
Address 2:	     		
Address 3:	     		
City:	     	State:	     	Zip:	     		
	
Office Phone*:	     	Mobile Phone:	     		
	
Reason for Creating New Account (Specify):
     	
Disclaimer:
The documents and data you will be able to access were prepared for NJ Department of Transportation utilizing State and/or Federal Funds. Its distribution is restricted and it may not be admissible in court, nor discoverable under OPRA. 

By requesting this User ID, you are agreeing to properly protect this information, and to never provide this information to anyone outside of the Department (with the exception of an Engineering Consultant hired SPECIFICALLY by the NJDOT to work on a project in the proximity of the bridge) without prior clearance from the Bureau of Structural Evaluation and Bridge Management.
	
Signature:	     		Date:	     		
	
Department Action:      

Role Assigned:      

*Required Fields