Created: 4/13/2012
CoMBIS User Account Information Sheet
(For County Administrator ONLY)	
This Information Sheet is to be completed by the County Administrator and submitted to NJDOT at CountyCulvertInsp@dot.state.nj.us as an e-mail attachment with the subject CoMBIS - County Admin User Account.	
County Name*:	     				
Person Requesting – Name*:	     	– Title:	     		
Organization*:	     		
	
 CREATE New CoMBIS User Account for County Administrator:	
User Info:	
First Name*:	     	Last Name*:	     		
E-mail*:	     		
Current Job Title:	     		
Role*:	 County Administrator	
	
Address 1:	     		
Address 2:	     		
Address 3:	     		
City:	     	State:	     	Zip:	     		
	
Office Phone:	     	Mobile Phone:	     		
	
Reason for Creating New Account (Specify):
     	
 DELETE    EDIT
Existing CoMBIS User Account:	
First Name*:	     	Last Name*:	     		
Existing Role*:	     	E-mail *:	     		
New Role*:
In case of Edit only	     		
	
Reason for Deleting/Editing Existing Account (Specify):
     	
Comments:      	
*Required Fields