Rev3: 02/26/2015, Created: 4/13/2012
CombIS User Account Information Sheet
(For County, Municipal and Local Users)	
This Information Sheet is to be completed by County Administrator for the County, Municipal and/or Local Bridge Owner(s) and submitted to NJDOT at the e-mail address CountyCulvertInsp@dot.nj.gov as an e-mail attachment with the subject “CombIS: Owner User Account”.	
	
County*:	     	Municipal/Local Owner*:	      		
Person Requesting – Name*:	     	– Title:	     		
Consultant Name (for Consultants acting as Municipal/Local Owner):	     		
	
CREATE New CombIS User Account for County, Municipal and Local Users (Check ONE):	
 County          Municipal           Local Bridge Owner          Other           Unknown 	
If “Other”, indicate name:	     		
User Info:	
First Name*:	     	Last Name*:	     		
E-mail*:	     		
Role*:	 County Administrator          County General Access                County Maintenance Access
 County Project Manager      County Support Access                Local Bridge Owner 
 Municipal General Access   Municipal Maintenance Access   Municipal Manager	
	
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