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(your company)
Request for Network & Technology Access

Instructions: Type or print employee information. Fill in applicable sections for requested systems.
The employee must read and sign the disclosure agreement prior to approval by the required
authorizing signature. Keep a copy for your files and forward original form to (IT Dept). If assistance is
needed to complete the form please contact (IT help desk and ext.). If deleting access, only Section 1 is
required.

Section: 1 (Must be completed) OPERATOR INFORMATION

Date required: __________ ADD DELETE CHANGE (to existing security)

Employee Name: ________________ Employee Title: _______________ Employee Extension: ______

Manager/Supervisor: ______________ Department: _________ Badge Access (Hours/Days): _______
Employee Status: FT PT TEMP Start Date: ____________ Term Date: ___________

COMPUTER SYSTEMS ACCESS

Access requested: Departmental & Subordinate Units Access to other Department Units
Drawings (Read Only) Drawings (Full Access)
Email Engineering
ERP (type/model)
TIP
Model Access after: ______________________________________________

COMPUTER SYSTEMS ASSETS

New PC If New PC: Standard Desktop (small form factor) ($ value)

Existing PC Engineering Workstation ($ value)
Existing PC Asset Tag: __________ Laptop ($ value)
Server BTO

SOFTWARE ASSETS

Software required on a new computer is assumed to be basic applications in order for functional email,
Internet access, operating system, and ERP connection to be made unless otherwise noted. Pricings
are for information only and are derived from (vendor) as of (date).

Software Required on New Standard PC: Other Software Requested: ________________________

Adobe Acrobat Professional ($ value) __________________________________
Microsoft Office 2007 Professional ($ value) __________________________________
Microsoft Windows Server Client Access License ($ value) __________________________________
Citrix / (ERP licensing ($ value) __________________________________

PRINTING

Network printers are available for connection in the following areas: (Select at least one)

Accounting Marketing
Engineering Purchasing
Engineering (Hallway) Quality

Desktop / local printer ____________________________

 Logon ID Security

You have been granted access to the (your company) computer systems. The login ID(s) and
passwords(s) issued to you is your means of access to these systems. They are to be used
solely in connection with performance of your authorized job functions. You should take all
necessary steps to prevent anyone from gaining knowledge of your login ID(s) and
password(s). The use of your Login ID(s) and password(s) by anyone other that yourself is
prohibited and should be reported to the Information Technology Department Administration
immediately.

NON-DISCLOSURE AGREEMENT
(your company) records, including both written documents and electronic data are to be
regarded as confidential.
This data is to be used only for intended purposes and that those responsible for the data take
reasonable precautions to prevent misuse of it. Protection of (your company) records and
compliance with Network and Internet Security Policies rest upon the individuals entrusted
with access to data. The non-disclosure agreement below is intended to define the employee's
responsibility in safeguarding sensitive information and to record his or her recognition and
acceptance of that responsibility.
Within (your company) anyone whose designated duties require access to network data or any
electronic information that is contained within property belonging to (your company) may use
that information for appropriate research and development, job functions and responsibilities,
training, or other service functions. Along with that access is the responsibility to safeguard
the individual's right to privacy and maintain the confidentiality of all records. Recognizing the
responsibility, I have regarding my access to student and/or employee records, I agree to the
following:

• I will access (your company) electronic data only as required to perform assigned
duties.
• I will store information under secure conditions and make every effort to ensure the
security, integrity, and continuity of (your company) information.
• I will not release suppressed or private information without authorization and I will
not publicly discuss records in a way that might personally identify an employee or
company operations and trade secrets.
• Unless release of public information is regarding as part of my job, I will notify my
supervisor immediately of any request I receive for public records.

I have read the above statements. I understand it, and I agree to comply with its contents.
I understand that if I violate any of the terms of agreement I am subject to disciplinary action.

 Employee Signature/Date:________________________________________________________

Section 2: (Must be completed) AUTHORIZED APPROVALS

 Signature_________________________________________________________________________
Supervisor/Department Head/Director Approval
Original: Personnel File
CC: Employee, I.T. Department