Access Authority Request Form

ACCESS AUTHORITY REQUEST FORM

Parties and Identification

Requestor Name:

Authorizing Officer Name:

Recitals

WHEREAS, Requestor Name: (the "Requestor") requires temporary or ongoing authorized access to certain systems, facilities and information controlled by the Authorizing Organization for the performance of defined duties; and

WHEREAS, Authorizing Organization: (the "Authorizer") has authority to grant, monitor and revoke such access in accordance with applicable policies and this Agreement; and

WHEREAS, the parties wish to define the scope, duration, conditions, and responsibilities attendant to such access and to memorialize required assurances concerning confidentiality, security, and compliance.

Scope of Work / Purpose of Access

Access Details

Access Type (select all that apply):

Physical facility access
Network / system access
Application / database access
Remote / VPN access
Other (specify):

Requested Access Start Date:     Requested Access End Date:

Security and Compliance Preconditions

The Requestor confirms completion of required preconditions (check all that apply):

Background check completed
Security and privacy training completed
Confidentiality agreement executed
Other (specify):

Payment Terms

If fees apply, the parties agree as follows.

Late payment fee:

Term and Termination

Term Commencement Date:     Term Expiration Date:

Either party may terminate access immediately for material breach, security compromise, or unlawful conduct; upon termination the Requestor must promptly return or destroy all credentials, badges, keys, and copies of Authorizer data in accordance with Authorizer instructions.

Confidentiality and Data Protection

The Requestor will treat all non-public information accessed pursuant to this authority as Confidential Information. Requestor shall not disclose, copy, store, transmit, or use such Confidential Information except as strictly necessary to perform the Scope of Work and in accordance with the Authorizer's security policies. Requestor shall implement and maintain reasonable administrative, physical, and technical safeguards to protect Confidential Information against unauthorized access, disclosure, alteration or destruction. Any suspected data breach or unauthorized disclosure must be reported to the Authorizer immediately and in no event later than 24 hours after discovery.

Representations, Warranties and Liability

Requestor represents and warrants that access will be used only for the authorized purposes set forth herein, that Requestor will comply with all applicable laws and Authorizer policies, and that Requestor's personnel granted access possess the necessary clearances and qualifications. Requestor agrees to indemnify and hold harmless the Authorizer for losses arising from Requestor's negligent or willful misuse of access, subject to any limitations required by applicable law.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its conflicts of law principles.

Entire Agreement

This Access Authority Request Form, together with any attachments, exhibits and executed confidentiality instruments specifically referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior discussions, proposals and agreements. No amendment will be effective unless executed in writing by duly authorized representatives of both parties.

Administrative Approvals

IT Provisioning Completed: Yes     Badge Issued: Yes

Acknowledgement and Certification

By signing below, the Requestor certifies that the information provided in this form is true and complete, that the Requestor understands and will abide by the terms contained herein, and that unauthorized use of access may result in disciplinary action, termination of access privileges, civil liability, or criminal prosecution.

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