Skip to content
Forms Menu
User Change Request
User Change Request
MADD User Change Request Form
Action to be Taken
Select User Type
Setup New User
Update Existing User
Terminate Current User
Leave of Absence for User
Requester Information
Requester's Name
Requester Email
User's MADD Office
Location
Please select...
0100 AL State Office
0400 AZ State Office
0402 AZ Southern
0600 CA Northern Sacramento
0604 CA Bakersfield
0610 CA Central Valley
0611 CA Southern, Los Angeles
0612 CA Riverside
0613 CA Orange Co
0614 CA San Diego
0633 CA San Bernardino
0639 CA Bay Area
0800 CO State Office
0801 CO Colorado Springs
0900 CT State Office
1002 DE Delaware
1200 FL State Office
1204 FL South
1207 FL Central
1223 FL Northwest
1240 FL Southwest
1244 FL West Central
1251 FL Northeast
1300 GA State Office
1400 PR Office
1505 HI State Office
1600 ID Boise Office
1700 IL State Office
1800 IN Indianapolis Office
2000 KS Topeka Office
2100 KY Louisville Office
2200 LA State Office
2302 ME Maine Chapter
2400 MD State Office
2500 MA State Office
2600 MI State Office
2700 MN State Office
2800 MS State Office
2900 MO Central
2912 MO Gateway
2918 MO Bootheel Co
2928 MO Heartland
2929 MO Newton/Jasper Co
2930 MO Ozark Mountain
3100 NE State Office
3203 NV Lyon Co
3400 NJ New Jersey
3500 NM State Office
3600 NY Albany
3622 NY State Office
3700 NC State Office
3900 OH State Office
3902 OH Northeastern
4000 OK Office
4124 OR Eugene
4200 PA State Office
4400 RI State Office
4500 SC State Office
4700 TN State Office
4711 TN Northeast
4731 TN West
4732 TN Upper Cumberland
4800 TX State Office
4809 TX North
4811 TX West
4814 TX Southeast
4815 TX Bryan
4817 TX Beaumont
4842 TX South
4843 TX Edinburg
4853 TX East
4880 TX Grants Office
4901 UT Salt Lake City Office
5002 VT Vermont
5100 VA State Office
5101 VA Northern
5300 WA Washington
5448 WV State Office
National Office
Type of Employee
Select Type of Employee
MADD Office Employee
Home Office Employee
Contract Employee
Intern / Temp
Employee Phone Number
Employee Extension
User Information
Legal Last Name
Middle Initial
Legal First Name
Preferred First Name
Department
Please select...
0100 AL State Office
0400 AZ State Office
0402 AZ Southern
0500 AR Little Rock Office
0600 CA Northern Sacramento
0604 CA Bakersfield
0610 CA Central Valley
0611 CA Southern, Los Angeles
0612 CA Riverside
0613 CA Orange Co
0614 CA San Diego
0633 CA San Bernardino
0639 CA Bay Area
0800 CO State Office
0801 CO Colo Springs
0900 CT State Office
1002 DE Delaware
1200 FL State Office
1204 FL South
1207 FL Central
1223 FL Northwest
1240 FL Southwest
1244 FL West Central
1251 FL Northeast
1300 GA State Office
1400 PR Office
1505 HI State Office
1600 ID Boise Office
1700 IL State Office
1800 IN Indianpolis Office
2000 KS Topeka Office
2100 KY Frankfort Office
2124 KY Nelson Co Chapter
2200 LA State Office
2302 ME Maine Chapter
2400 MD State Office
2500 MA State Office
2600 MI State Office
2700 MN State Office
2800 MS State Office
2900 MO Central
2912 MO Gateway
2918 MO Bootheel Co
2928 MO Heartland
2929 MO Newton/Jasper Co
2930 MO Ozark Mountain
3100 NE State Office
3203 NV Lyon Co
3400 NJ New Jersey
3500 NM State Office
3600 NY Albany
3622 NY State Office
3700 NC State Office
3900 OH State Office
3902 OH Northeastern
4000 OK City Office
4124 OR Eugene
4200 PA State Office
4400 RI State Office
4500 SC State Office
4700 TN State Office
4711 TN Northeast
4731 TN West
4732 TN Upper Cumberland
4800 TX State Office
4809 TX North
4811 TX West
4814 TX Southeast
4815 TX Bryan
4817 TX Beaumont
4842 TX South
4843 TX Edinburg
4853 TX East
4880 TX Grants Office
4901 UT Salt Lake City Office
5002 VT Vermont
5100 VA State Office
5101 VA Northern
5300 WA Washington
5448 WV State Office
5500 WI Wisconsin Office
Executive Assistant
National - Field Relations
National - Finance
National - Giving and Marketing
National - Human Resources
National - Information Technology
National - Legal
National - Programs
National - Victim Services
Title
Please select...
Administrative Assistant
Affiliate Executive Director
Assistant Development Officer
Coordinator of Volunteer Resources
Court Monitoring Project Specialist
Development Officer
Lead Victim Services Specialist
Manager Victim Services
Office Administrator
Program Coordinator
Program Director
Program Manager
Program Specialist
Special Events Manager
Senior Office Administrator
State Executive Director
Victim Advocate
Victim Services Specialist
Volunteer Resources Specialist
Walk Manager
OTHER:
Other Title (maximum 35 characters)
Supervisor
User Needing Update
User Updates
Update to Occur
Name
Title
Department/Office
Supervisor
Enter New Name
Enter New Title
Please select...
Administrative Assistant
Affiliate Executive Director
Assistant Development Officer
Coordinator of Volunteer Resources
Court Monitoring Project Specialist
Development Officer
Lead Victim Services Specialist
Manager Victim Services
Office Administrator
Program Coordinator
Program Director
Program Manager
Program Specialist
Special Events Manager
Sr. Office Administrator
State Executive Director
Victim Advocate
Victim Services Specialist
Volunteer Resources Specialist
Walk Manager
OTHER:
Other New Title
Enter New Department/Office
Please select...
0100 AL State Office
0400 AZ State Office
0402 AZ Southern
0500 AR Little Rock Office
0600 CA Northern Sacramento
0604 CA Bakersfield
0610 CA Central Valley
0611 CA Southern, Los Angeles
0612 CA Riverside
0613 CA Orange Co
0614 CA San Diego
0633 CA San Bernardino
0639 CA Bay Area
0800 CO State Office
0801 CO Colo Springs
0900 CT State Office
1002 DE Delaware
1200 FL State Office
1204 FL South
1207 FL Central
1223 FL Northwest
1240 FL Southwest
1244 FL West Central
1251 FL Northeast
1300 GA State Office
1400 PR Office
1505 HI State Office
1600 ID Boise Office
1700 IL State Office
1800 IN Indianpolis Office
2000 KS Topeka Office
2100 KY Frankfort Office
2124 KY Nelson Co Chapter
2200 LA State Office
2302 ME Maine Chapter
2400 MD State Office
2500 MA State Office
2600 MI State Office
2700 MN State Office
2800 MS State Office
2900 MO Central
2912 MO Gateway
2918 MO Bootheel Co
2928 MO Heartland
2929 MO Newton/Jasper Co
2930 MO Ozark Mountain
3100 NE State Office
3203 NV Lyon Co
3400 NJ New Jersey
3500 NM State Office
3600 NY Albany
3622 NY State Office
3700 NC State Office
3900 OH State Office
3902 OH Northeastern
4000 OK City Office
4124 OR Eugene
4200 PA State Office
4400 RI State Office
4500 SC State Office
4700 TN State Office
4711 TN Northeast
4731 TN West
4732 TN Upper Cumberland
4800 TX State Office
4809 TX North
4811 TX West
4814 TX Southeast
4842 TX South
4853 TX East
4901 UT Salt Lake City Office
5002 VT Vermont
5100 VA State Office
5101 VA Northern
5300 WA Washington
5448 WV State Office
National - Field Relations
National - Finance
National - Giving and Marketing
National - Human Resources
National - Information Technology
National - Legal
National - Programs
National - Victim Services
Enter OLD Supervisor's Name
Enter NEW Supervisor's Name
MADD Office Address
Office Number and Street Name
Office Suite Number
Office City
Office State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Office Zip Code
Home Office Address
Home Number and Street
Home Suite Number
Home City
Home State
Please select...
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Home Zip
New User: Salesforce Access
Please select the level(s) of access (if any) that the new user will need:
Constituent Management
VIP
Victim Services
Court Monitoring
Volunteer Management
Will this user be the primary volunteer contact for the MADD Office
Yes
No
User Termination
User Name for Termination
Forward Terminated User Email to
User Leave of Absence
User Name for LOA
Enable or Disable User
Please select...
Disable and forward
Enable
Forward only
LOA User Email Address To Be Sent To:
Equipment Assigned to User
Computer Service Tag
Effective Date and Time (Central Time)
Effective Date
Effective Time (Central Time)
Please select...
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
Additional Information
Additional Requester Notes
Limit of 250 characters
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information