Access Request Setup Form

Access Request Setup Form

Recitals

WHEREAS, Service Provider and Requesting Organization (collectively, the Parties) desire that the Service Provider configure, provision, and maintain user access to the information systems and resources identified in this form in accordance with the terms and conditions set forth herein;

WHEREAS, the Requesting Organization requires that access be granted only to authorized personnel for legitimate business purposes and that the Service Provider shall implement requested access in compliance with applicable security policies, data protection obligations, and instructions contained in this request;

WHEREAS, the Parties agree that the provision of access and any related services shall be governed by the payment, confidentiality, term, and termination provisions set forth in this document.

Service Provider:

Requesting Organization:

Effective Date of Request:

Scope of Work

Deliverables include creation and configuration of user accounts, assignment of roles/groups, application of security controls, and execution of onboarding tasks as detailed below. Service Provider shall perform services in a professional manner consistent with industry standards.

Access Details

Requested Access Type:

Read Write Admin Other:

Security Controls Required:

Multi-factor Authentication required VPN access required Privileged account

Data Classification (select all that apply):

Public Internal Confidential Restricted

Payment Terms

Fee Amount: $. Services rendered under this request shall be billed in accordance with the schedule below.

Late Payment: Unpaid amounts shall incur a late fee of on the outstanding balance, compounded monthly, to the extent permitted by law.

Term and Termination

Term Start Date: Term End Date:

Either Party may terminate this request and any associated services for convenience upon written notice of days. Termination for material breach is effective immediately upon written notice if the breaching Party fails to cure within days after receipt of notice.

Confidentiality

Each Party shall maintain the confidentiality of information accessed or exchanged in connection with this request and shall not disclose such information to any third party except as required by law or with the other Party’s prior written consent. Provider shall implement technical and administrative safeguards appropriate to the sensitivity of the data and shall ensure that all personnel with access are bound by confidentiality obligations at least as protective as those contained herein.

Governing Law

This Access Request and any dispute arising out of or relating to it shall be governed by the laws of the state of without regard to its conflict of laws rules.

Notices

Entire Agreement

This document, together with any attachments and approved change orders, constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals and communications, whether written or oral. Any amendment must be in writing and signed by authorized representatives of both Parties.

Acknowledgment and Certification

By submitting this Access Request, the Requester certifies that the information provided is accurate, that access is required for legitimate business purposes, and that the Requester and the Requesting Organization will comply with all applicable policies and all applicable laws in connection with access and use of the resources.

I certify the statements above and request that the Service Provider proceed with the access setup in accordance with this form.

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