ࡱ>  @ Rgbjbjqq ". Y 2:::8gl)ha:<?(@?@?@?!@ABpX``````$CcRev`iCG!@!@CGCG`@?@?Ka!L!L!LCGL@?@?X!LCGX!L!L,N|N@?i q`.:G4NPaa0aN fGH f$N fNPCC!LkDtDdCCC``"3 L3REMOTE ACCESS SERVICE REQUEST Michigan Department of Information Technology SECTION I  EMPLOYEE Information (Card Holder)1. Last NameFirst NameInit2. Email Address FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT      3. SOM Agency / Office / Division / Section / Unit FORMTEXT      4. Business Street Address5. Business CityStateZip FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT      6. Business Phone No.Extension7. Last 4 digits SS#8. Birth Date (month & day only-mmdd)( FORMTEXT    )  FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      9. State User Access10. Vendor Name FORMCHECKBOX State Employee FORMCHECKBOX Contractor / Vendor  FORMTEXT      SECTION II  SERVICE REQUESTED (Check all that are needed)1.  FORMCHECKBOX SecureID (Authentication Only) FORMCHECKBOX Dial-in FORMCHECKBOX VPN Client FORMCHECKBOX Gateway- to Gateway VPNToken (If checked, also check one below)(If checked, also check one below)(If checked, also check one below)(If checked, also check one below) FORMCHECKBOX Software ID FORMCHECKBOX Employee FORMCHECKBOX Vendor FORMCHECKBOX Employee FORMCHECKBOX Vendor FORMCHECKBOX Employee  FORMCHECKBOX VendorType FORMCHECKBOX Key FobRGWSUVPNRGWVVPNDial-in or VPN Group Name (If known) FORMTEXT      2. Access requested: Destination, TCP/IP Port FORMTEXT      3. Change Access Type  Existing assigned token only4. Reissue  No Division Approval required for reissueAdd: FORMCHECKBOX Dial-in/ROAM FORMCHECKBOX VPN FORMCHECKBOX ReissueRemove: FORMCHECKBOX Dial-in/ROAM FORMCHECKBOX VPN5. Cancel Token  FORMCHECKBOX Lost FORMCHECKBOX Expired6. Token Serial # / Tunnel Name(Check One) FORMCHECKBOX No longer needed FORMCHECKBOX Defective / Damaged FORMTEXT T V X l n p z | ~ X Z n p r | ~       . jhb\UhWjhb\Uhjhb\Uj'hb\Ujhb\Ujh@UmHnHujhb\Ujhb\U hW5 hb\;h~mhb\6< ( 2 T P+!P+z|z@ |p|b|$If]^ $If^$Ifskd$$Ifs4g+1,   01,4 saf4p !x$If%(fgT V ~ d^!^ !^P.P$If]P^.$Ifkd$$Ifs4\g +& 01,4 saf4 V bTK+|$If]^kdK$$Ifs4\g\+u 01,4 saf4V X K+!6(q|$If]^`kd$$Ifsg+1,01,4 sa.$Ifakdu$$Ifs4g+1,01,4 saf4  @ b |||PJq!J!J!J!.$Ifkd$$Ifs4\g_!$+Wx01,4 saf4$If]^$If. 0 2 < > @ B V X Z ^ ` b d x z |  @ B D F H \ ^ ` f h l n ڿںڿگڤڙڎjhb\Uj5hb\Ujhb\Uj hb\U hb\6 hW5j hb\Uj hb\Uhb\jh@UmHnHujhb\UjW hb\U7 B b\$ |\g|Nm |\|$If]^$Ifkd $$Ifs4\g_!$+Wx01,4 saf4B D d^$ !^g!^m !^!.$Ifkd $$Ifs4\gq + MS 01,4 saf4   V X Z v x z  Z\|ҺүҤ֠֜~yg#hOhK5CJOJQJ^JaJ ho0v5hCho0v56hKhO6hKhC6hCho0vh~mjhUjHhUj|hUjhU hW5hhWhb\jh@UmHnHujhb\Ujhb\U$ 6 V bY|Y| $Ifgdkd$$Ifs4\gq + MS 01,4 saf4V X | ~)!s|~!ju|_! .($Ifgd $Ifgd <$Ifgd .$$Ifa$gdtkd$$Ifl40g+W01,4 laf4A8 8p 8 8) 8 $Ifgd~mkd$$Ifl4rgh q +oM01,4 laf4pQ I!x$IfkdV$$Ifs4rgh+V01,4 saf4"2Vl{h0\Q\>;<$If]^gd-Q <$IfgdO -$$Ifa$gdO<$If]^gdC-$If]^gdWskd$$Ifs4g+1,   01,4 saf4p  24PRTln ԾгАЅzskaZa hc 6aJhKhK6aJhc hK5 hK5CJjhKUj#hKUjhKUhChK56hChK56CJaJhChKCJaJ hChKjhKUhKjhKU hOhKCJOJQJ^JaJ#hOhK5CJOJQJ^JaJl- $<$Ifa$gdC-$$If]^a$gdkd$$Ifs4ִg !+t n!  01,    4 saf4 .QtZdD[# D[ D[ D[ $Ifgd%$$If]^gd-Q $If^gd-Q $IfgdCO$p$If]^pa$gdc  -.PQstuvw   '()1278F˵˪˟˔ˉ~y hc 5jH$hc Ujf#hc Uj"hc Uj"hc UjV!hc Uj hc Ujhc Uhc jhc Uhc hc 5 hK5hKhKhKCJ aJ hKhK6CJ aJ /tuvO|;2 -$Ifgdc $p$If]^pa$gdc kd$$Ifs4rg +`@J    01,4 saf4*127=YZ$p$If]^pa$gdc Ffe($If]^gdK$If]^gd-Q$If]^gdW$If]^gdC -$IfgdW$If]^gdc FGHZbdghkl  $&ļΌ|qfhc 5CJOJQJj 8hc Uh6hXhc 5CJOJQJaJh6hXhc OJQJaJhc CJOJQJjhc UmHnHuj2hc UhCOhc 6hKhc 6aJ hc 5hc 6CJ aJ h@hc 6CJ aJ hc jhc Uj?+hc U&7IQRSTUVWXYZcdlm=YFfA/$If]^gdc $If]^gd-Q$If]^gdW$If]^gdC -$IfgdW$If]^gdc  -$Ifgdc m |!|PPSG`1G1 =$Ifgd6hXkd2$$Ifs4FgB *+ 01,    4 saf4 <$Ifgd| .$Ifgd &<$If^&gdCO "$&Ԕ111E 111ԔK+|}wK+!.$Ifakdm7$$Ifs4g+1,01,4 saf4$IfFf{5 =$Ifgd6hX =d$IfgdO N |k| $IfgdT)~ $Ifgder`kd8$$Ifsg+1,01,4 sa5|u!j|a!jI|u&!Vm| ($IfgdT)~ .$IfgdT)~ <$IfgdT)~ .$$Ifa$gdT)~ $IfgdT)~tkd9$$Ifl40gU+C01,4 laf4"#123ABPQRjkyz{衜{j Dhc UjOChc UjBhc U hc 6 hc 5j@hc Uj?hc Uj>hc Uj}=hc Uj^;hc Uj:hc Uhc jhc Uj4:hc U0"+PS"5| $IfgdT)~kd;$$Ifl4֞gt u 4US+ k!E01,4 laf4"4ASWX!|!I|k| .$IfgdT)~ <$IfgdT)~ .$$Ifa$gdT)~XYj|>PS8S|0|(|P$If<$If$Ifkd>$$Ifl4ֈgt u 4U+ k!C01,4 laf4|%|m|.kdfA$$Ifl4ֈgOVS++oE01,4 laf4P$If<$If\S||||%|m!.$IfP$If<$If $If^gdT)~     SECTION III  AUTHORIZED REQUESTOR APPROVALS1. Authorized Requestor Name2. Telephone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      3. Authorized Requestor SignatureDate4. Division Approver Name5. Telephone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      6. Division Approver SignatureDateSECTION IV  BILLING INFORMATION1a.1b.1c.1d.1e.1f.1g.1h.1i.1j.1k.1l.AGYINDEXPCACOBJAOBJGRANTPHPROJPHAG 1AG 2AG 3 FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT      FORMTEXT      FORMTEXT      When the above information has been completed, fax this form to (517) 241-8016.HELP DESK USE ONLY1. Ticket Number2. Assigned by:3. Assigned Date4. Billing IP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      SERVICE DELIVERY USE ONLY  NEW4. Token Serial #5. SecurID Administrator Signature (Required)6. Start Date FORMTEXT       FORMTEXT      SERVICE DELIVERY USE ONLY  CANCEL Note: DIT will continue to charge Agency until Token is returned or reported lost7. Token Received by Signature8. End Date FORMTEXT       FORMCHECKBOX Labor Units FORMTEXT   Code(NLROAM) DIT-0051 Rev. 02/08  PAGE 1 of  NUMPAGES 1 DISTRIBUTION: FAX to 517  241- 8016 \ \ \\\\\n\p\\\\\\\\\\]]]]] ]$]&]:]<]>]H]J]L]N]]]]]^^^^^^&^(^,^.^B^D^F^L^N^R^T^h^j^l^v^x^z^jOhc UjNhc UjNhc UjIhc UjHhc Uj1Hhc U hc 5hc jhc UmHnHuUjhc U=\\\<3Y+1 =$Ifgd8@kdD$$Ifl4ֈgOVS++oE01,4 laf4\\n\p\1skdF$$Ifl4g+1,   01,4 laf4p !x$Ifhkd F$$Ifl4g+1,01,4 laf4p p\\\\\L]2|O ||2!|O !.$IfvkdG$$Ifl40gq+ '01,4 laf4$IfL]N]]]2|O |$IfvkdJ$$Ifl4@0gq+ '01,4 laf4]]]]2|O |$IftkdvK$$Ifl40gq+ '01,4 laf4]]]^2|O | $Ifgd vkdKL$$Ifl40gq+ '01,4 laf4^^*^z^2O  -$IfgdStkd2M$$Ifl40gq+ '01,4 laf4z^|^^^2|xO | $Ifgd $IfgdStkdP$$Ifl40gq+ '01,4 laf4z^|^^^^^^^_______``` `` `"`,`.`0`2`F`H`J`T`V`X`Z`n`p`r`z`|`~`````````ߦߖ߆vj]h2 hc CJUj*]h2 hc CJUj\h2 hc CJUj.\h2 hc CJUh!Whc CJjhc CJUmHnHuj[hvhc CJU hc CJjhc CJU hShc hc  hc 5.^^^^2|O | $Ifgd tkdTQ$$Ifl40gq+ '01,4 laf4^^_{ !x$Ifgd #vkd)R$$Ifl40gq+ '01,4 laf4___ _(_0_8_@_H_P_X_`_h_|l||||N||||||$$If]^a$gd # $$Ifa$gd 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fffBfpjb#!_! .x$Ifgd_)'.$Ifkdq$$Ifl40g#+:$ 01,4 laf4pBfDfFfjfffffn/c!c!X|X|E|X |;P$If]^gdI{; ;P$IfgdI{; .$IfgdI{;kd`s$$Ifl40g#+:$ 01,4 laf4pffffffffffffffffffgggg|||b|     :    b P+<:P+P+<: $ !)Ff3~ $IfgdI{;Ffx;P$If]^gdI{; ;P$IfgdI{;fffffffffg g ggggg&g(gg@gBggggggлȪ⊆hE.hh*WhhiX0J8CJaJmHnHuh h0J8CJaJ!jh h0J8CJUaJhiX0J8CJmHnHuh0J8CJjh0J8CJU hh*WCJ hCJ hb\CJ h&Xhc hc  hhYhc + 0&P/ =!@"@#$%@$$If!vh51,#v1,:V s4   01,51,/ 44 saf4p $$If!vh55& 55#v#v& #v#v:V s401,55& 55/ / / / / 44 saf4DText23Enter Employee Last NameDText24Enter Employee First NamevDText25DText44Enter employee Email address($$If!vh55u 55#v#vu #v#v:V s401,55u 55/ / / / / / 44 saf4$$If!vh51,#v1,:V s401,51,/ 44 saf4DSText194Enter the Agency, Office, Division, Section and Unit$$If!vh51,#v1,:V s01,51,/ / 44 sa$$If!vh5W55x5#vW#v#vx#v:V s401,5W55x5/ / / / / 44 saf4D%Enter Business Street AddressDText26Enter Business CityDText27Enter Business 2 digit StateD ClientZip UppercaseCEnter the Business Zip (+4 if known) (Example: 48909 or 48909-7537)$$If!vh5W55x5#vW#v#vx#v:V s401,5W55x5/  / / / / 44 saf4$$$If!vh5 5M5S 5#v #vM#vS #v:V s401,5 5M5S 5/ / / / / / 44 saf4D  SuperAreaCode000 Enter the Supervisor's Area CodeSuperPhoneNumberD CoPhoneNumber2Enter the 7 digit phone number (Example: 373-1234) CoExtensionDWorkerExtension5Enter the extension number, if any, (Example: X12345)DText4>Enter the last 4 digits of the Employee Social Security NumberDText287Enter the Employee Month /Day of birth in MM/DD format.($$If!vh5 5M5S 5#v #vM#vS #v:V s401,5 5M5S 5/  / / / / / 44 saf4$$If!vh5W5#vW#v:V l401,5W5/ 4af4DeCheck1,Check if User Access if for a State EmployeeDeCheck20Check if User Access if for Contractor / CompanyD2Text31*If Vendor Acces, enter Vendor Company Namen$$If!vh555o5M5#v#v#vo#vM#v:V l401,555o5M5/ / / / / / / / 4af4p$$If!vh55V555#v#vV#v#v#v:V s401,55V555/  / / / /  / / /  / / / / 44 saf4$$If!vh51,#v1,:V s4   01,51,/ 44 saf4p DeCheck184Check if requesting a SecureID (Authentication Only)DeCheck if requesting Dial-inDeCheck if requesting VPA ClientDe*Check if requesting Gateway to Gateway VPN$$If!vh5t5 55n55! 55 #vt#v #v#vn#v#v! #v#v :V s401,5t5 55n55! 55 /  / / / /  / / / /  / / / /  / / 44 saf4Q$$If!vh5@5J 5 5 5 #v@#vJ #v #v #v :V s401,+5@5J 5 5 5 /  / / /  / / / 44 saf4DeCheck17%Check if request is for user dial-in.DeCheck17%Check if request is for user dial-in.De#Check if requesting vendor dial-in.De#Check if requesting user VPA ClientDe&Check if requesting vendor VPA Client.De=Check if requesting user RGWSUVPN for Gateway to Gateway VPN.De>Check if requesting RGWVVPN for Vendor Gateway to Gateway VPN.7$$If!vh5@55m555e5#55 5 5 5 m5 5 h5?#v@#v#vm#v#v#ve#v##v#v #v #v #v m#v #v h#v?:V s401,+5@55m555e5#55 5 5 5 m5 5 h5?/ / / / / / / / / / / / / / /  / / / / / / / / / / / 44 saf4kd,%$$Ifs4Ng  R_!%Y'+ @me#mh?01,<<<<4 saf4DeCheck17%Check if request is for user dial-in.@$$If!vh5@55m555e5#55 5 5 5 m5 5 h5?#v@#v#vm#v#v#ve#v##v#v #v #v #v m#v #v h#v?:V s401,5@55m555e5#55 5 5 5 m5 5 h5?/ /  / / / /  / / /  / / / /  / / /  / / / / /  / /  / / / / 44 saf4kd+$$Ifs4Ng  R_!%Y'+@me#mh?01,<<<<4 saf4D0Text33(If VPN is checked, enter VPN Group Name.$$If!vh5 55#v #v#v:V s401,5 55/ /  /  / / / 44 saf4$$If!v h5F 5555k55+ 5g5 #vF #v#v#v#vk#v#v+ #vg#v :V s401,5F 5555k55+ 5g5 /  / / /  / 44 saf4kd3$$Ifs4 gq V~<'(+F k+ g01,$$$$4 saf4$$If!vh51,#v1,:V s401,51,/ 44 saf4DText476Describe access requested: destination, TCP/IP Port. $$If!vh51,#v1,:V s01,51,/ 44 sa$$If!vh55C#v#vC:V l401,55C/ 4af4DeCheck10Check if ReissueDeCheck8Check if Add VPNDeCheck10Check if Reissue$$If!vh5 55k55!55E#v #v#vk#v#v!#v#vE:V l401,5 55k55!55E/ / / / / / / / / 4af4DeCheck if Remove Dial-in/ROAMDeCheck9Check if Remove VPN9$$If!vh5 55k55!5C#v #v#vk#v#v!#vC:V l401,5 55k55!5C/ / / / / 4af4DeCheck11"Check if SecurID Return is DamagedDeCheck12"Check if SecurID Return is Expired+$$If!vh5+555o55E#v+#v#v#vo#v#vE:V l401,5+555o55E/ / / / 4af4DeCheck13#Check if SecurID Return is CanceledDeCheck14$Check if SecurID Return is DefectiveD%Text41%Enter Return Card Token Serial Number=$$If!vh5+555o55E#v+#v#v#vo#v#vE:V l401,5+555o55E/ / / / / 4af4$$If!vh51,#v1,:V l401,51,/ / 4af4p $$If!vh51,#v1,:V l4   01,51,/ / 4af4p $$If!vh5 5'#v #v':V l401,5 5'/ 4af4D8&Enter the authorized requestor's name.D  SuperAreaCode000%Enter the Division Director Area Code D CoPhoneNumberDEnter the 7 digit Division Director phone number (Example: 373-1234)$$If!vh5 5'#v #v':V l4@01,5 5'/ 4af4$$If!vh5 5'#v #v':V l401,5 5'/ / / / 4af4$$If!vh5 5'#v #v':V l401,5 5'/  / / / / 4af4$$If!vh5 5'#v #v':V l401,5 5'/ /  /  / 4af4D8Text29!Enter Security Administrator NameD 000*Enter the Security Administrator Area CodeDIEnter the 7 digit Security Administrator phone number (Example: 373-1234)$$If!vh5 5'#v #v':V l401,5 5'/  / / /  4af4$$If!vh5 5'#v #v':V l401,5 5'/ /  /  / 4af4$$If!vh5 5'#v #v':V l401,5 5'/  / / /  4af4$$If!vh51,#v1,:V l4   01,51,/ / 4af4p $$If!v h5g55|5u55&555 5 5 5 #vg#v#v|#vu#v#v&#v#v#v #v #v #v :V l401,5g55|5u55&555 5 5 5 / 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