1.0 General Information

Form submitted by:

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

Describe security measures applied to systems:*

Additional Information:

By the nature of using a POS system, the guidelines set for in the Data Stewardship Policy 1114 and Cash Handling Policy 2105 must be followed.

2.0 Vendor Information

Vendor Name:*

Vendor Contact Name:*

Vendor E-mail * Vendor Phone*

Vendor Server IP address or Server name:*

Vendor Physical Address:*

3.0 System Administration

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

Alternate phone number:

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.

I have read and agree to comply with University Policies 1301, 1114 and 2105. Yes No

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 POS Network assignment

Date  ___/____/____   

Signature: _____________________________________

4.0 Department Information

This entire section is required.

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

As a department head for * , I certify that the above computer is required, critical for the function of my department.

I also certify that, the best of my knowledge, the designated System Administrator(s), listed above, understand(s) what is required to maintain and secure the systems listed in F0040_B and that the department will provide the required departmental support to maintain these systems securely. 

If the above system administrator(s) or departmental contact leaves the University, or is absent for an extended period of time, the department will notify Network Engineering & Technology 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 and the relevant University Policies involved (1301, 1114 and 2105). I also understand that if any information is missing or improperly filled out, it may delay POS Network assignment.

Department Head:* Title: *

Date: ___/___/____

Signature: ____________________________________

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

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