Per George Mason University’s Public Internet Address Policy 1304, the requesting department is required to provide the following information prior to permission being granted for the computer to be publicly addressable. Please review F0046, Serve Zone Requests prior to submitting request.

Instructions - PLEASE READ - Updated June 20, 2008

This form is for use if you are requesting a zone of 5 IP's or larger for research or academic use. This is not to be used for departmental administrative purposes.

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.

Note:  If this request is to provide off-campus access to your system, the ITU can provide SSL Virtual Private Network (VPN) access which may be able to serve your needs more effectively than providing your computer with a Public Internet Address.  For information on this option, see NET-F0021, Staff Telework VPN Request (http://tsd.gmu.edu/net/forms.html).

All machines in this zone must be used for research and not for departmental purposes. Network Engineering & Technology will perform routine scans of the Serve Zones in order to check for improper use of Zones. Once Serve Zone has been approved, the System Administrator will be contacted to discuss how to register individual machines into the IP Control System. A F0050, Multiple System Information Spreadsheet may be required to be completed.

1. Serve Zone Requirements

How many systems (IP's to be assigned) will be in the Serve Zone?*

What research is being done by the department requiring multiple Serve Zone assignments:*

2.0 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.

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 IP address assignment

Date  ___/____/____   

Signature: _____________________________________

3.0 Department Information

This entire section is required.

As a department head for * , I certify that the above network requested is purely for research. No departmental functions (web server, mail server, etc.) will be allowed on this Serve Zone.

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 computer and that the department will provide the required departmental support to maintain this computer 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 at noc@gmu.edu that a temporary Administrator/Contact is being assigned until a permanent one 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 IP address assignment.

Department Head Name:*

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.

If necessary, use this button to .

For Administrative Use Only

IP Addresses Assigned:________________________ Date Assigned: ______________________

Work Completed by: _________________________