DHHS ITD: Aid to County (ATC) Request Form

Support Type *

User Request *

NCID Username *

First Name *

Middle Initial

Last Name *

Title *

Division *

Address *

City *

State *

Zip Code *

County *

Phone *

Email *

Default User Role *

Aid to County User

State User Role Request

State Office Division

Division of Public Health (DPH)

Division of Information Technology (ITD/DIRM)

County User Role Request

ITD Application Support Role Request

County Office

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