Form submitted by:

* Name: *E-mail: * Extension: 3-

1.0 System information

*Type of Request: New Change

If this is a change request: Current IP Address and a brief description of the change:

Location of computer: 

* Building:  

* Room:          * Extension:      

* Is this machine located in the Thompson Data Center or the Prince William Campus Disaster Recovery site?

Yes No (if Yes, the Firewall Request form A0020 will need to be completed as well, under IP, enter requested.)

* Is this machine used to process Credit Cards? Yes No (if Yes, then form F0040, POS Network Assignment Request or F0041, POS IP Address Assignment Request must be completed)

* GMU Barcode/ Serial Number:

* Hardware type make and model: If this is a printer, please attempt to connect to your printer using Dynamic DNS. Contact the Support Center for an explanation/assistance.

* MAC Address:

* Operating System - Select both the type from the top line and enter the OS specifics in the column below

Does this machine have multiple interfaces, IPs or DNS names? If yes, check here and also fill out
form F00x4_B (this link will open a new window).

* Will this computer use Reserved DHCP? Yes No Current IP address (if Static):
* Will this system have a DNS name? Yes No
Name: .gmu.edu

DNS names will be assigned on a first-come, first-served basis. ITU reserves the right to revoke any DNS assignment at any time.Systems with names in the gmu.edu domain (dog.gmu.edu, cat.gmu.edu, etc) may take up to 2 business days for the name to be approved by Client Relations before the name can be assigned.

Which of the following services will be implemented on this computer:
WWW (port 80) FTP E-Mail P2P Remote Access
Other Services

* Describe security measures applied to computer:

The Data Stewardship Policy 1114 gives examples of "highly sensitive data" such as individual financial records, social security numbers, credit card information and proprietary data protected by law or international agreement. 

* Is highly sensitive data or regulated data stored on this computer? 

Yes No

If yes, please provide a description of the data being stored?

Additional Information:

2.0 System Administration

* Primary Contact Name:
* Primary Contact E-mail
* Primary Contact Campus phone: 3-

Alternate phone number:

* Department Contact Name:
* Department Contact E-mail
Department Contact Campus phone: 3-

Additional Contact Information:

As the Administrator of this system, I have read and understand my Job Responsibilities as listed in the Responsible Use of Computing Policy 1301.I will monitor the security and function of this computer and, in the event of any suspicious activity, will contact the Support Center.

By signing this form, I affirm that I have read and understand this form. I also understand that if any information is missing or improperly filled out, it may delay IP address assignment

Date  ___/____/____   

Signature: _____________________________________

3.0 Department Information

This entire section is required.

As a department head for* , I certify that the above computer is required, critical for the function of my department, to have a Public Internet Address to perform the following tasks: *

I also certify that, the best of my knowledge, the designated System Administrator(s), * , understand(s) what is required to maintain and secure the above computer and that the department will provide the required departmental support to maintain this computer securely. 

If the above system administrator(s) leaves the University, or is absent for an extended period of time, the department will notify Network Engineering & Technology at noc@gmu.edu that a temporary System Administrator(s) is being assigned until a permanent System Administrator(s) is assigned.

By signing this form, I also affirm that I have read and understand this form. I also understand that if any information is missing or improperly filled out, it may delay IP address assignment.

* Department Contact:  * Title:

* Department Head:

Date: ___/___/____

Signature: ____________________________________

After filling out this form,

This form will print when submitted. Please fax signed forms to 703-993-3505. it so that a work order can be created.

If necessary, use this button to .