Today’s Date: ______/_______/______

CONTACT INFORMATION

First Name:______________________  Last Name: _________________________________

CBU E-mail address: _______________________ Phone Number: _____________________

Building: (Circle one)

1) Rozier    2) Maurelian    3) Stritch    4) O'Hara Hall    5) 604 E. Parkway    6) 170 Oakdale    7) Avery

Room Number: _____________     Jack #: _______________  Mailbox #: _______________

SERVER / WORKSTATION INFORMATION

MAC Address: ______:______:______:______:______:______

Operating System: (Please check all that apply)

_____Windows     95,     98,    Me,     NT,    2000      XP      (circle version)
_____Macintosh OS Version:_____________(fill in version)
_____Unix/Linux: ______________________(specify type)
_____Other:___________________________(specify)

Are you running a server?     No    Yes      Type of Server_______________________

Requested DNS Name:_________________________________________________

Reason for Request:___________________________________________________

___________________________________________________________________

___________________________________________________________________

FORM MUST BE COMPLETELY FILLED BEFORE IT CAN BE PROCESSED!!

For Office Use Only	Internal IP Address: 192.168._______._______
Work Order #: _____________________	External IP Address: 66.192._______._______