Requestor Information
Requesting Institution:
*
UMB
UMBC
CES
UMCP
UMES
MBI
USM
TU
UMUC
Requestor's Name:
*
Requestor's Email:
*
Date of Request:
Entity Information
Entity Identification Number (to keep):
*
Entity Identification Number (to be deleted):
*
Additional Identification Numbers (to be deleted):
,
Entity's Last Name/Org. Name:
*
Entity's First Name:
Entity's Middle Name:
Home Address to remain active:
Preferred
Home Telephone Number:
Business Address to remain active:
Preferred
Business Telephone Number:
Email Address / Website URL:
Supplemental Information
Additional Information
Reason for Request:
Duplicate Record
Record Created in Error
Explanation:
