Request Date - Los Angeles Unified School District



Request Date ___|___|___ Request # ____ __ ___

Instructions

Use this form to request approval and identification of new IP addresses.

Leave Request # blank, this field is reserved for S&P.

For more forms, please visit or contact the Standards and Procedures Section (S&P), 333 Beaudry Ave., 10th floor.

SYSTEM NAME: __________________________________________________________________________________________

________________________________________________________________________________________________________________

SYSTEM DESCRIPTION: (Including system functions, Databases, etc.) _____________________________________________

________________________________________________________________________________________________________________

ARCHITECTURE DESCRIPTION: (Attach Visio Diagram)_______________________________________________________

_____________________________________________________________________________

Proposed DNS Name:_____________________________ Requested Hostname:____________________

Internal Service Requested: Web __ Secure Web __ Mail __ Secure Shell __

DMZ _______ Internal Ports: __________ __________ __________

Justification: ______________________________________________________________________________

_________________________________________________________________________________________

External Service Requested: (Bulletin K-24 must accompany this request)



ADMINISTRATIVE CONTACT:

• Name: ________________________________________ Title ________________________________

• School/Office Name _____________________________ Phone # _____________________________

• Email _________________________________________

TECHNICAL CONTACT:

• Name: ________________________________________ Title ________________________________

• School/Office Name ______________________________ Phone # ____________________________

Email __________________________________________

Approval: (Director from requesting Department)

• Signature ____________________________Title ________________________________ Date _____________

AUTHORIZATION (For ITD use only)

Signature Date Phone #

Operating Systems Section _________________________________ ___|___|___ ____________

Database Section _________________________________ ___|___|___ ____________

Network Section _________________________________ ___|___|___ ____________

Security Section _________________________________ ___|___|___ ____________

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Detailed Instructions

Use this form to request new IP addresses.

This form is to be used for all mainframe, mini, personal computer systems, and networks.

Leave Request # blank, this field is reserved for S&P.

3. For more forms, please visit or contact the Standards and Procedures Section (S&P), 333 Beaudry Ave., 10th floor.

Systems

Name of the system.

Describe the system.

Describe the Architecture of the system. Attach Visio diagrams.

Firewall Definitions

• Provide Proposed DNS.

• Provide Hostname.

• Provide Services (Web, Secure Web, Mail, and Secure Shell). To place server in DMZ, specify security zone. (internal, external, webdmz, vpndmz, ect.)

• Provide description to all required ports & justifications.

User Organization

Provide office title(s) and LAUSD location code(s) of user organization(s).

Provide name(s) and job title(s) of contact person(s) of user organization(s).

9. Provide name(s) and job title(s) of person(s) of user organization(s) who will approve and accept project deliverables.

Authorization

10. The Operating Systems Section, Database Section, Network Section, and Security Section must all sign to certify the request. Requests not approved will be returned.

11. Assigned Internal IP Address

Submission

If a manager or specialist initiated the form, he/she should sign, date, and provide phone number.

13. The ITD director submitting the request should sign, date, and provide phone number. Please forward to the leo.tam@ or deliver to Standards And Procedures Section, 333 Beaudry Ave., 10th floor for processing.

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| ASSIGNED INTERNAL IP ADDRESS __ __ __. __ __ __. __ __ __. __ __ __ | |

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