IT Resources and Systems Access Request Form (Exception)
Fill Out This Form, Print, Sign and Submit to User Support Services Located in the Coyner Building. Need Help Finding Us? *denotes Required Fields
Date of Request:
Access to and use of IT resources and systems by persons not directly affiliated with Longwood must involve work to be preformed which satisfies at least (1) of the following conditions:
- the work relates to or is in support of Longwood's sponsored activities.
- the work involves use of IT resources and systems available only from Longwood and can be accommodated without disruption to established Longwood workloads.
*Full name of person needing access (MUST include middle initial):
*Describe the access needed and, if appropriate, attach corresponding and completed access request forms:
Duration (Not to exceed (1) year):
*Start Date: *End Date:
Please provide any
pertinent technical contact information (name,
company/business phone #, etc.):
Sponsor must be a Longwood University employee and agrees to assume responsibility for use and adherence to the Acceptable Use of Information Technology Resources and System Policy #6104 by the person named above.
*Sponsor's Name:
*Phone:
*Sponsor's Dept:
*Email:
*Sponsor's Signature: ______________________________ *Date: ____/____/____
Sponsor must submit this request in writing to the Vice President of Information & Instructional Technology Services/Chief Information Officer (CIO), or his/her designee, for approval. (Please deliver to User Support Services for routing.) Under no circumstances can the sponsor authorize this access.
Approved_____ Denied_____
Comments: _________________________________________
*CIO/Designee's Signature: __________________________ *Date: ____/____/____
Approved requests will be forwarded to
Information Security for processing.
Denied requests will be returned to Sponsor.
See Access to Information Technology Resources and Systems #6105 for more information.
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