Instructions - PLEASE READ - Updated June 20, 2008

Per University Policy 1302 all departments wishing to have install their own Wireless Local Area Network must register their network. This form is to be used by any group wishing to register a wireless access point for use by their department. Completing this form does NOT guarantee approval, but starts the approval process. All fields on this form are required. Once the form is completed, please have the Department Head sign, then fax the form to Network Engineering at 703-993-3505.

Department

Building Room

Department Contact

Name E-mail Phone

Jack # This is the jack the wireless access point will be plugged into. If there will be multiple access points, please include the listing in the "Reason for Wireless" field.

Reason for Wireless

Intended Users and applications

Security measures to be implemented to ensure that only above users access Wireless Network, please include type, model and number of acess points

As a department head for , I certify that the above Wireless LAN is required and critical for the function of my department.

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 Wireless LAN and that the department will provide the required departmental support to maintain this network securely. I understand that in the case of a security issue, this Wireless LAN will be shut down until the machine behind the access point can be assesed, quarantined, and remediation has been completed as accepted by University guidelines.  

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 wireless@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 approval.

Department Head: Title:

Date: ___/___/____

Signature: ____________________________________

This form will print when submitted. Please fax signed forms to 703-993-3505. this form so that a tracking ticket can be created.

If necessary, use this button to .