Access Change Request

ACCESS CHANGE REQUEST

Parties and Recitals

Requesting Party:   Requesting Party Company:

Approving Party:   Approving Party Company:

WHEREAS, Requesting Party requires a change to access privileges for specific information systems and user accounts to perform business functions in accordance with corporate policy and applicable contractual obligations; and

WHEREAS, Approving Party is responsible for authorizing and provisioning access on the systems identified herein and represents that granting such access is consistent with Approving Party's security obligations and least-privilege principles; and

WHEREAS, the parties desire to document the requested change, scope of work, payment (if any), timelines, approvals and confidentiality obligations relating to this Access Change Request.

Request Details

Grant access    Modify access    Revoke access

Effective Date:   Expected End Date (if temporary):   Priority: Normal High Emergency

Approvals and Processing

Approver Name:   Approver Title:

Approval Date:   IT Processor:   Processing Target Date:

Has the user completed required training related to this access?   Yes   No

Payment Terms (If Applicable)

If the requested change is billable under an existing service arrangement, the following payment terms apply. Parties must complete the payment fields below where applicable; absence of amounts indicates non-billable work.

Payment Terms Clause: Unless otherwise expressly agreed in writing, billed amounts are due within the payment schedule above. Late payments shall accrue interest as specified in the Late Fee field and the non-defaulting party may suspend any further provisioning of billable services after providing seven (7) days' written notice of intent to suspend.

Term, Termination and Notice

Term Start Date:   Term End Date:

Notice Period for Termination:

Termination Clause: Either party may terminate this Request or any provisioning obligation for cause if the other party materially breaches its obligations and fails to cure within the Notice Period specified above. In addition, Approving Party may suspend or revoke access immediately if required to protect systems, data integrity or to comply with applicable law, provided the Approving Party provides written notice to the Requesting Party as soon as practicable.

Confidentiality

Confidentiality Clause: Each party shall maintain in confidence all non-public confidential information obtained in connection with this Request and shall not disclose such information except to employees, contractors or affiliates having a need to know and who are bound by confidentiality obligations no less protective than those set forth herein. Confidentiality obligations shall survive termination of this Request for a period of years.

Representations, Warranties and Compliance

Authority: The Requesting Party represents and warrants that the individual submitting this Request has the requisite authority to request these changes on behalf of the Requesting Party and that the requested access is appropriate and lawful for the business purpose described.

Compliance with Policy: The parties shall comply with all applicable security policies, data protection requirements, and contractual obligations in carrying out the changes requested herein. Unauthorized use or sharing of credentials is strictly prohibited.

Governing Law; Entire Agreement

Governing Law: This Request and any dispute arising from it shall be governed by and construed in accordance with the laws of the state or jurisdiction selected by the parties: , without regard to conflict of law principles.

Entire Agreement: This Access Change Request, together with any incorporated references to an underlying master services agreement or security policy expressly incorporated in writing, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior discussions and understandings. Any modification must be in writing and signed by authorized representatives of both parties.

Acknowledgment and Certification

By signing below, the Requesting Party certifies that the information contained in this Request is true and accurate, that the requested access is necessary for the business purpose stated, and that the Requesting Party will comply with all applicable policies and controls. The Approving Party certifies that it has reviewed and authorized the requested change consistent with its duties and responsibilities.

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