Form Oit 0115 – Fill Out and Use This PDF

Statewide Office of Information Security

Garden State Network

Remote Access Registration Form

For

State Employee

VPN

GoToMyPC

Air Card / MPN

Initial Credential ID:

Other

Group ID:

Complete sections I, II and III of this form, sign in the requested area and forward it to your Agency’s Supervisor for approval and signature in section IV. After receipt of this form, the Authorizing Entity will provide instructions for setting up your Remote Access to the Garden State Network.

I. Registrant Information (Type or print clearly and complete all fields)

Name:

Agency/Organizational Unit:

Street Address:

City, State, Zip Code:

Contact Telephone:

E-mail Address:

II. Justification

1.Requesting Remote Access to the Garden State Network for access to the following system(s):

2.Require this access for the following purpose:

3.Type of Remote Access Requested (Check only one)

GoToMyPC

Email Address:

I understand that this access is limited to desktop or workstation access only, and may not be shared:

Initialize

VPN (Credential)

Device MAC Address:

I certify that I have received and will utilize State issued equipment to access the State of NJ VPN and may not be shared:

Initialize

OIT-0115 1/11

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III. Registrants Acknowledgment (Signature of registrant required)

As a user of the State of New Jersey Garden State Network Remote Access, I understand that the confidentiality and protection of the State’s information is of the utmost importance. I have read and understand the State’s Policy on the

acceptable use of the Garden State Network Remote Access..

If I receive access to the Garden State Network Remote Access, I will use it only for authorized purposes. I will notify the Authorizing Entity immediately if I believe that another person may have obtained unauthorized access.

I understand that all information transmitted or received through the Garden State Network Remote Access is the property of the State and is to be used for State business only. I further understand that representatives of the State are authorized to monitor the use of the Garden State Network Remote Access.

I attest that the information submitted on this form is correct. I am aware that any violation of the Garden State Network’s Remote Access Policy may subject me to disciplinary action; loss of Remote Access privileges and that

unlawful use of the Garden State Network Remote Access may result in civil liability, criminal liability or both.

Print Name

Signature:

Date:

IV. Supervisor’s Approval (Signature of registrant’s supervisor is required)

The above individual has been approved to acquire Remote Access on behalf of:

(Project/Program Name) NOTE: Must be filled in

I understand that it will be my responsibility to notify my agency’s CIO (or designee) in a manner prescribed by the

agency’s internal policy, immediately upon learning that this individual is no longer employed with the agency, that his/her authorization to access the Garden State Network (GSN) on behalf of the agency has been withdrawn, or if any misuse of the Remote Access mechanism or unauthorized access to the GSN has occurred.

Print Supervisor’s Name

Signature:							Date:
Title:
V. Authorizing Entity’s Approval
CIO, CTO (or Designee) Signature:							Date:
Print Designee Name					Title:

OIT-0115 1/11

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Statewide Office of Information Security