Free Virtual Private Network Request Form-blank.PDF - Indiana

State Form 50695 (11-01)

Virtual Private Network Request Form
Agency Name: Telephone Number:

Agency Information: Date:

Agency Data/Security Coordinator: Requestor Information and Approvals: Employee Name: Office: Supervisor Name: AU Billing Code: KC

Telephone Number: Supervisor Signature: IDEM Accounting Approval:

Justification for needing VPN access: (include cost/benefit analysis and applications to be used)

Note: The cost of service is $20.00 per month, per user. There is a $5.00 one-time helpdesk set up fee. There is a 1 year commitment for this service thru May, 2002. The state will re-evaluate the vendor and the service next year before a renewal is sought. The total cost of the service will not exceed $245 for the year. VPN Usage Agreement: During my use of the State of Indiana Virtual Private Network (VPN), I will follow the guidelines and restrictions as stated in the IDEM User Agreement. I will protect my VPN certificate and will not share the certificate or password with anyone. I understand that violating the User Agreement will mean immediate removal of my access to the VPN. During my VPN subscription, I understand that I may be subject to security audits by IDEM IT Personnel. I also understand that VPN usage is tied to my IDEM position and the VPN access will be reevaluated if my position changes. Name (Print): Signature:

Security Coordinator Information: YES New Certificate requested? Need Certificate revoked? If user is to be restricted to certain IP addresses or applications, they are to be noted here: 1. 2. REF: AUTH: NO

Virtual Private Network (VPN) Access
Contact: Data /Security Coordinator @ 232-7010

Step 1:Complete the Virtual Private Network (VPN) Request Form. The following fields are required: ? Employee Name ? Telephone Number ? Office ? Supervisor Name ? Supervisor Signature ? Accounting Unit Billing Code or KC# ? Justification ? Requestor's Signature Step 2:The employee's supervisor must sign The Request Form. Step 3:The Form is forwarded to the Agency Data/Security Coordinator. Step 4:The Agency Data/Security Coordinator will obtain IDEM fiscal approval and forward these forms to DoIT Security for activation. DoIT will provide the Coordinator with the access codes within 2 business days. Step 5:When the Agency Data/Security Coordinator receives the access codes, the requestor will be contacted by the Help Desk to schedule installation of the VPN client on the requestor's computer.