[COMPANY NAME]

Information Technology Access

Request Form

Please fill out all fields as appropriate, and return form to the Information Technology Department for further processing and handling. Some
network access rights require additional approval from Management, or Human Resources. You will be advised of any access not provided,
and the declining party. Incomplete forms will be returned for completion.

ACCEPTABLE USE STATEMENT FOR [SHORT NAME] COMPUTING RESOURCES

The following document outlines standards for use of the computing systems and facilities located at or operated by [COMPANY
NAME], ([SHORT NAME]) and its employees. The definition of [SHORT NAME] systems and computing facilities will include any
computer, server or network provided, supported, or used by [SHORT NAME]. Use of the computer facilities includes the use of
data/programs stored or transferred on [SHORT NAME] computing systems, data/programs stored on CD ROM, hard drives, flash
media, or any other storage media that is owned and maintained by [SHORT NAME]. The "user" of the system is the person requesting
or possessing an account (or accounts) in order to access [SHORT NAME] computing resources. The purpose of these standards is to
ensure that all [SHORT NAME] users use the [SHORT NAME] computing facilities in an effective, efficient, ethical and lawful manner.
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All [SHORT NAME] computing resources are for lawful and authorized business use only. All information that is generated,
documented and/or communicated using [SHORT NAME] computer resources is [SHORT NAME]'s property. [SHORT NAME]
reserves the right to monitor, inspect, review, restrict or retain any computing resources, activities, or records on, or accessed
via [SHORT NAME] computer resources.
Users are to engage in business appropriate conduct. Fraudulent, defamatory, threatening, harassing or obscene messages
and/or materials shall not be sent from, to, or stored on [SHORT NAME] systems.
Users are not to transmit, distribute, copy, or store data in violation of any applicable law, regulation, or client agreement. This
includes, without limitation, material protected by government controls, copyright, trademark, trade secret, proprietary
information, or other intellectual property right without documented permission from the owner on file with IT and HR.
[SHORT NAME] provides all appropriate hardware for usage by users. Usage of non-company hardware, including laptops,
smartphones, USB flash drives or other media, connecting to company resources is to be approved in writing by Information
Technology and non-company hardware will not be supported by [SHORT NAME] IT.
Access to any [SHORT NAME] internal or external resources are exclusively for use in the performance of [SHORT NAME]
business. Users shall not share their [SHORT NAME] internal or external account(s) and/or password(s), with anyone other
than Information Technology, or an officer of the company without written authorization on file with Information Technology and
Human Resources. This includes, but is not limited to sharing the password to an account, providing access by entering a
password for others to use, using incremental passwords, or utilizing any other manual or automated password delivery
mechanism (printed forms, Post-it Notes, Roboform, PasswordManager, etc).
Users shall not purposely engage in activity with the intent to: degrade the performance of systems; deprive an authorized
[SHORT NAME] user access to a [SHORT NAME] internal or external resource; obtain extra resources beyond those
allocated; circumvent [SHORT NAME] computer security measures or gain access to a [SHORT NAME] internal or external
resource for which proper authorization has not been given.
Users shall not utilize computers for personal use, except standard items as permitted during designated breaks and
lunchtimes or as defined by management.
Users shall refer any requests for specific internal information regarding [SHORT NAME] Information Technology and security
practices to Information Technology.
Users are required to report any weaknesses in [SHORT NAME] computer security, any incidents of possible misuse or
violation of this user agreement to Information Technology, including, but not limited to data leaks, exposed or shared
passwords, etc.

Any noncompliance with these standards will constitute a security violation and may result in disciplinary action, including termination.
Violations of some of these standards may result in civil or criminal investigations and/or prosecution. More detailed information can be
found in Policy XXX XXXXXXXXXXX (if you have another policy)

ACCESS REQUEST SUBMISSION FLOW

Please allow 1 full business day for processing
Requestor
Information Technology
Human Resources
Information Technology
File

Complete the form with all known information, and submit the form to Information Technology for review and
processing. If needed, request assistance in filling out the form.
Reviews and validates the requested access, technical details, and implications of access, then forwards
the form to H.R. for final approval. Additional parties may be consulted to verify appropriate request.
Reviews I.T. actions, confirms approved access, and returns to I.T. for processing.
Creates, modifies, or deletes account as per request (and modifications), updates requestor on status of
approvals or denials of access, and tests account as appropriate.
Information Technology retains original on-file and provides a copy to HR for personnel folder. Contracts
Administrator will keep an additional copy in Docuware.

USER ACKNOWLEDGEMENT AND SIGNATURE

[COMPANY NAME]

Information Technology Access

Request Form

Please fill out all fields as appropriate, and return form to the Information Technology Department for further processing and handling. Some
network access rights require additional approval from Management, or Human Resources. You will be advised of any access not provided,
and the declining party. Incomplete forms will be returned for completion.
I have received a copy of, read, and understand the [SHORT NAME] Information Technology Acceptable Use Statement for [SHORT NAME] Computing
Resources, and agree to abide by these statements. I will notify [SHORT NAME] Information Technology immediately upon violation of any of these statements
for proper security handling.
Name of User (Please Print): ________________________________________________________________________________
Signature of User: ________________________________________________________________________________ Date:___________________________