Banner Mines-Affiliate CWID Application/Authorization
(Custom Role Authorization)
Mines’ better-known business processes serve the needs of our recruits, applicants, students, faculty, and employees. Many others who are not in
one of these roles, however, are affiliated with Mines. These affiliations are listed below. These affiliates are typically on campus for reasons other
than employees of Mines who need services that may include; access to labs, computer resources, the library, etc. This form initiates the process
to provide “Mines-affiliates” with the services they need by enabling entry into our administrative data system and assignment of a Campus-Wide
Identification Number or “CWID.” A CWID is necessary to obtain many services on campus, including a BlasterCard. (This form will NOT provide
those services by itself.)
This completed and authorized form should be submitted to CCIT or HR with a government issued picture ID, or sent as an attachment to a Mines Help Center request
with a legible scanned copy of a government issued picture ID from the Applicant.
Part 1: Applicant Information (to be completed by the Applicant)
The following is the minimum information required to insure you are not already in our system. All fields must be legibly completed and must match a
picture ID containing your address. You will not be assigned a CWID unless all of these requirements are met. All data is private and will not be
published or released.
Please Type or Print Legibly (all fields are required, except where indicated):
Mines Help Center SR # or name of referring staff member: ______________________________
Name: (Family Name(s)) / (First Name) / (Middle Name(s)) .
Full Mailing Address (street address, city, state zip): ________________________________________________________________________________________
Date of Birth: M _______/ D ______/ Y ________ Gender: M___ F___ SSN (optional): _____________________
Phone(s) (indicate business/home/cel ): _____________________________________________________________
E-mail Address(es) (indicate business/personal): ______________________________________________________
Do you have a previous affiliation with CSM (if yes, explain)? ___________________________________________________________________________
Have you ever been issued a CWID or Blaster Card (if yes, provide CWID and explain)? _____________________________________________________
Applicant Signature: ___________________________________________________________________________ Date: M _______/ D ______/ Y _______
Part 2: Access Request (to be completed by the Department Sponsor)
What access are you requesting for this person? (Use other side if more space is needed for explanation):
Mines Emergency Alert (MEA)
Explain why the above access is needed:
Description of Applicant’s Mines affiliation/role: __________________________________________________________________________________
Affiliation Start Date: M_____/ D_____/ Y______ Affiliation End Date: M_____/ D_____/ Y______ (Roles wil be applied/extended for up to one year at a time.)
Applicant’s Position Title: ___________________________________ Applicant’s Department: ___________________________
I am the Sponsor for the individual named in Part 1, and certify that s/he is affiliated with Mines in the role described.
Sponsor Name: __________________________________________ /______________________________________ (please print)
Print Last Name Print First Name
Title:____________________________________________________ Department ______________________________________
Sponsor Signature: ___________________________________________________ Date: M ______/ D ______/ Y _______ Phone No:_______________
Part 3: Department/Division Head or Dean Authorization
I certify the individual named in Part 1 is affiliated with Mines in the role described in Part 2, and I authorize the request in Part 2.
Authorization Name: __________________________________________ /______________________________________ (please print)
Print Last Name Print First Name
Title:_____________________________________________________ Department ______________________________________
Authorization Signature: _________________________________________________ Date: M ______/ D _____/ Y ______ Phone No:________________
Part 4: General Person Entry (to be completed by HR or CCIT Staff member entering data into Banner)
Custom Role Applied:
Alumni Assoc Emp
Picture ID type: ______________________ Date entered M _______/ D ______/ Y _______ by person: _____________________________________
CWID found or assigned: _________________________
NOTE: Completed Authorization Form with scanned ID should be kept in a secure/locked location in the Department or Office of the person who entered the data.
Last Modified: 6-JUN -2017