7/25/2019 VPN Request Form v2.0

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MediAssistIndiaTPAPvtLtd

Department of IT

VPN Request Form

Employee Consultant Vendor

VPN User Information

*EMP ID: __________________________________ *Name: _________________________________

*Dept: ____________________________________ *Location: _______________________________

*Windows ID: ________________ *CMS ID: ________________ *CMS Role: ___________________

*Email ID: _________________________________ *Designation: ____________________________

*Host or Application Access:____________________________________________________________

__________________________________________________________________________________

*Reason for VPN connectivity: __________________________________________________________

__________________________________________________________________________________

Declaration:

I am responsible for any data loss, data leakage, suspected fraudulent and any illegalActivity with or without notice of mine through this VPN connection.

_____________________________________ _______________________________*Employee Signature Date

Name of approver (HOD or BM): ________________________________

I am agreeing with above reasons and Recommending for VPN connectivity as the user is authorized towork on Medi Assist applications from outside the Medi Assist network.

Approver Contact: ______________________________________________________*Signature of approver (HOD or BM): Email ID: _______________________

For Network Team Internal Use:

Completed By: ________________________ Group Assigned: _________________

___________________________________________ ____________________________________

*Approved by IT (Manager or HOD) Date