Remote Access Authorization Form

To access BSU enterprise data from a remote location, employees must complete the steps below.

1 • For specific information on BSU’s Secure Remote Access, see 2 http://it.bridgew.edu/policy/RemoteAccess.cfm 3 4 • For specific information on standards for Secure Remote Access see 5 http://it.bridgew.edu/policy/StandardSecureRemoteAccess.doc 6 By signing this form, the applicant agrees to have read and abide by all of the appropriate policies listed in the documents above and comply with the required standards. Send completed forms to: Security Manager, Room 009, Boyden Hall. Request Section Remote Access Applicant (print) Organization Phone Number

Signature of Remote Access Applicant Date Email Address

Reason Requested (include applications to access):

Requested Systems:

Duration Requested:

Supervisor/Department Head Section The Supervisor/Department Head must support the request for the applicant to be given permission to access enterprise data from a remote location.

Supervisor name (print) Signature of Supervisor Authorization status Date Approved � Denied �

Information Technology Approval Section AVP/CIO name (print) Signature of AVP/CIO Authorization status Date Approved � Denied �

Authorized Systems:

Information Technology Performance Section RSA Token Serial number

Information Technology Staff member Date