Northern Ohio Educational Computer Association

Virtual Private Network “VPN” Authorization Form

Date: ________________ District Name _____________________________________________

Requestor’s Name: _________________________________________________________________

VPN User Name: __________________________________________________________________

VPN User E-Mail Address: __________________________________________________________

Access IP Addresses and/or Range: ____________________________________________________

Reason for Request: ________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Requestor’s Signature: _____________________________________________ Date: __________

Tech Coordinator’s Signature: ______________________________________ Date: ___________

Superintendent’s Signature: _________________________________________ Date: ___________

User acknowledges that any machine connecting to the network, MUST have all up to date patches and service packs installed and virus protection with current definitions. They districts also acknowledges that by allowing this individual VPN access, that the district accepts responsibility to advise NOECA when VPN access is to be terminated.

Signatures constitute approval at the district level Please return to:

NOECA

219 Howard Drive

Sandusky, Ohio 44870

PH: 419.627.1439 FAX: 419.627.5608

NOECA USE ONLY:

GROUP NAME: ________________________________________

USER NAME: _________________________________________

IP ADDRESS: ______________________________ SUBNET:_____________________

Initials: __________________

Notification Contact: __________________ Notification Date: __________