ETSS Network Access Request Form


ETSS NETWORK ACCESS REQUEST PROCEDURE
All requests for access to ETSS protected applications and services must be approved by the ETSS Information Security Assessment Unit (ISA). Please complete and submit this form to ISA to request or remove access to/from protected applications and services. Allow 3 - 5 days for this request to be processed.
(*) Required fields
	Request Type	Grant Access	Remove Access
Requestor/Approver Contact Information
Requestor Name*:		Date Requested *:
Requestor Dept.*:		Date Required*:
Requestor Unit:		Requestor E-mail*:
Technical Contact Name/Phone*:
Approver (Dept. Manager Name/Phone):
Access Description/Justification (Please work with your technical contact to provide the following information)
Request Description (e.g., access to database; environment - Prodution, Development, Test; Spcial ID; Application):

Access From*:		Access To*:
	Source IP Address(es) or domain name(s)		Destination IP Address(es)	Destination Port(s)
Source Location:
	Physical location of source computer (e.g., office)
Business Justification*:

	Brief Description of reason for access
Access Duration
Temporary Request*?:
No
Yes	Expiration Date*:

Please contact ETSS Information Security Assessment Unity (ISA) with questions, etss_isa@ncsu.edu