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CaIJOBSsM MIS Admin Registration Form <br />Please complete the following form by typing the information into each box. For assistance, please <br />contact the CaIJOBS Operations Unit at caljobsadmin@edd.ca.gov or 1-916-653-0202. <br />Requestor Information <br />* Requestor <br />N/A - No Change <br />* Requestor Email <br />* Phone Number <br />* Organization Name <br />* Sub -recipient Code <br />* Mailing address <br />Requested Accounts <br />User <br />User <br />*Type <br />(Add/Update/Delete) <br />N/A —No Change <br />N/A —No Change <br />* First Name <br />* Last Name <br />* lob Title <br />* ZIP Code <br />* Email <br />* Phone <br />SIGNATURE: The person signing below must be designated to represent the organization and has authority <br />to make changes to the information provided in this form. The signature authorizes the Employment <br />Development Department to make changes to its records as described above. <br />a 0 -4 A �' � <br />Signature of Requestor <br />Signature of Executiv irector <br />T ( ;z'-b-o'?�/ <br />Date <br />Date <br />Return completed and signed form to caljobsadmin@edd.ca.gov. <br />The requested username and a temporary password will be sent to the requested staff with a cc to the <br />Requestor. <br />Page 1 of 1 <br />