Instructions - PLEASE READ - Updated June 6, 2008

Fill out this form online then print the form prior to submitting. Submitting the completed form will generate a work ticket, however assignments will not be made without the signed forms. Fax signed forms to Network Engineering and Technology at 703-993-3505. All areas with bold italic print and asterisks (*) are required. Text in green are hyperlinks to policy pages or definitions for terms used on this form and why they are required. If multiple machines are being administered by the same System Administrator, then a single F0014_A can be illed out and a F0050, Multiple System Information Spreadsheet can be filled out and emailed to the Engineer assigned to the ticket.

Protect systems will not allow incoming connection from outside the George Mason University Network. If you wish to make a system accessable to the public Internet, please complete F0014_A, Public Internet Address Request instead of this form.

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:

* Reason for Static Assignment:

Location of system:

* Building:     * Room:      * Extension:

*Serial Number/GMU Barcode:

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 left column and enter the OS specifics in the right column.

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).

* 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)

* Will this computer use Reserved DHCP? Yes No Current IP address (if Static):
If used, will Dynamic DNS fulfill the need for reaching this system remotely? Yes No If No, why:

* Does this computer have a DNS name? Yes No
Name: .gmu.edu

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

* Department:
* System Admin Name:
* System Admin E-mail
* System Admin 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 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.

Date  ___/____/____   

Signature: _____________________________________

This form will print when submitted. Please fax signed forms to 703-993-3505. it to create a work order.
If necessary, use this button to .