Organization and Mailing Address

/ INFORMATION SYSTEMS SERVICES DIVISION (ISSD)
REMOTE ACCESS CUSTOMER
REGISTRATION
Please print.
See instructions on back page. / 1. ACCESS REGISTRATION
Dial Access Change
Virtual Private Network (VPN)
2. DATE
ORGANIZATION AND MAILING ADDRESS / TEMPLATE (ISSD USE ONLY)
3. DIVISION / 4. ACCOUNT CODE / 5. OFFICE
6. COMPLETE MAILING ADDRESS / CITY / STATE / ZIP CODE
CONTACT INFORMATION
7. LAST NAME / FIRST NAME / MIDDLE INITIAL / 8. MAIL STOP
9. TELEPHONE NUMBER (AND AREA CODE)
( ) / 10. FAX NUMBER (AND AREA CODE)
( ) / 11. EMAIL ADDRESS
CUSTOMER INFORMATION
12. LAST NAME / FIRST NAME / MIDDLE INITIAL / 13. TELEPHONE NUMBER (AND AREA CODE)
( ) / LOG-ON ID (ISSD USE ONLY)
14. CONNECTION TIME
Unlimited (with management approval)
Maximum of minutes (240 minutes default) / 15. EMAIL ADDRESS
CUSTOMER’S WORKSTATION CONFIGURATION
16. PC OPERATING SYSTEM
DOS WIN 3.x WIN95/98 WIN NT WFWG
Other (specify): / 17. PROTOCOLS REQUIRED FOR THIS CONNECTION
NetBeui TCP/IP IPX DLC/LLC
Other (specify):
VPN ONLY
18. HOST DESTINATION IP ADDRESSES OR SUBNET ADDRESS(ES) ON THE DSHS NETWORK
......
...... / VPN GROUP (ISSD USE ONLY)
APPROVING AUTHORITY
I hereby certify that I am formally authorized by the management of the division listed under Organization and Mailing Address above to approve remote access to the state’s wide area network for the person listed under Customer Information above. I have verified that the information on this form is correct. I have advised the persons identified as the Contact Person and Customer above that information gained by this access may be used ONLY for official DSHS business purposes. Furthermore, I have advised the persons identified above of issues related to protection of non-disclosable information and privacy constraints. Copies of Administrative Policies 15.14 and 15.15 have been provided to these individuals and the “Internet Access Request and Agreement” is signed and on file with this division.
19. LAST NAME / FIRST NAME / MIDDLE INITIAL / 20. TELEPHONE NUMBER
21. SIGNATURE / 22. E-MAIL ADDRESS
REMARKS
DISTRIBUTION / FOR ISSD USE ONLY
STATE AGENCIES SEND TO: / Completed by Network Services (NS):
Network Services
Remote Access Administration
Mail Stop: 45890
PO Box 45890
Olympia WA 98504-5890 / Email registrations from approving authority to:

with “Approved” in the subject line.
OR
FAX to (360) 902-7675 / Date: _____ INITIALS: ______
INSTRUCTIONS
NOTE: All field information is required unless otherwise noted in the instructions.
1. / Check the appropriate Access registration type.
2. / Enter the date this form is completed.

ORGANIZATION AND MAILING ADDRESS

3. / Enter the DSHS division acronym, such as AAA, HCS, DDD, etc.
4. / Enter the appropriate DSHS account code. If you do not know it, leave this field blank and Information Systems Services Division (ISSD) will enter it for you.

TEMPLATE (ISSD USE ONLY) LEAVE BLANK

5. / Enter the complete name of your office.
6. / Enter your complete mailing address.

CONTACT INFORMATION

7. / Enter the last name, first name, and middle initial of a person who can be contacted regarding this request.
8. / For state agencies only: / Enter your mail stop, if available. If you do not have a mail stop, enter your complete mailing address in line 6.
9. / Enter the contact person’s telephone number. You must include the area code.
10. / Enter the contact person’s FAX number. You must include the area code.
11. / Enter the contact person’s e-mail address (e.g., Doe, John (Exchange) or (Internet))

CUSTOMER INFORMATION

12. / Enter the last name, first name, and middle initial of the customer who will be using the Remote Access and Network Security (RANS) sevices. This information is critical (see Item 14 below).
13. / Enter the customer’s telephone number. You must include the area code.

LOG-ON ID (ISSD USE ONLY) LEAVE BLANK

ISSD will assign a log-on ID and notify the user. The log-on ID will consist of up to 5 characters of the last name, the first letter of the first and middle names, and a tie-breaker, if needed.
14. / Check the appropriate box for connection time. If connection time is to be limited, specify the number of minutes (the default is 240 minutes).
15. / Enter the customer’s e-mail address (e.g., Doe, John (Exchange) or (Internet)) (optional).

CUSTOMER’S WORKSTATION CONFIGURATION

16. / Check the operating system used by the workstation, such as Windows for Work Groups (WFWG), Windows 95, Windows NT.
17. / Enter the protocol(s) required by this connection.

VPN ONLY

18. / Enter the Host IP Address(es) of the hosts, servers or subnet that you want this customer to have access to. (Additional in remarks.)

VPN GROUP (ISSD USE ONLY) LEAVE BLANK

APPROVING AUTHORITY
19. / Enter the last name, first name, and middle initial of the DSHS approving authority authorizing remote access for this customer.
20. / Enter the telephone number of the DSHS approving authority authorizing remote access to the customer.
21. / Signature of DSHS approving authority.
22. / DSHS approving authority e-mail address.

REMARKS

Enter any pertinent information you think ISSD should know for establishing this connection.

DISTRIBUTION

Either email, mail or FAX the completed form per distribution instructions on the front of this form. After processing, ISSD will return a copy of the form with any ISSD-supplied information, such as the account code and user log-on ID.
If emailing completed form, it must be emailed to us from a DSHS division approving authority. Email completed registration from approving authority to with “Approved” in the subject line.

DSHS 02-549 (REV. 02/2000) BACK

INSTRUCTIONS