Employee Managed Services Form

EMPLOYEE MANAGED SERVICES FORM

Personal Information

Full legal name:

Position Information

Reporting manager:    Proposed start date:

Managed Services Requested

Select all services required for this employee:

Account provisioning (network and systems)
Email account / distribution lists / aliases
VPN / remote access
Administrator or elevated privileges
Laptop / desktop / mobile device assignment
Software installation / licensing
Cloud service access (storage, apps)
Other (specify below)

Business Justification & Access Level

Access level required:    Access expiration date (if temporary):

Hardware Assignment (if applicable)

Assigned date:    Expected return date:

Security, Data Handling & Confidentiality

Employee will have access to confidential or sensitive data: Yes

By requesting these services the employee acknowledges and agrees to comply with company security policies, to maintain the confidentiality of all proprietary information, and to follow procedures for secure handling, storage, and transmission of data. Access granted under this request may be suspended or revoked at any time for noncompliance or business need.

Service Levels & Support

Select preferred support priority:

Standard response (up to 5 business days)
Expedited response (1–2 business days)
Emergency (immediate assessment; limited scope)

Employment History (Most Recent Employers)

Title:    Dates employed:

Title:    Dates employed:

Education

Graduation date:    Major / field of study:

Professional References

Provide three professional references:

Relationship:    Phone:    Email:

Relationship:    Phone:    Email:

Relationship:    Phone:    Email:

Legal Disclosures & Authorizations

At-will employment: I acknowledge that my employment status is at-will, meaning either I or the company may terminate employment at any time, with or without cause or notice, except as otherwise provided by law or by a written agreement signed by authorized company representatives.

Equal Opportunity: The company provides equal employment opportunity to all employees and applicants without regard to protected characteristics as defined by applicable law and does not tolerate unlawful discrimination or harassment.

Authorization to contact previous employers and perform background checks: I authorize the company and its agents to contact previous employers, educational institutions, and references, and to obtain consumer and/or criminal background checks, verification of credentials, and any other information necessary to evaluate my suitability for employment and access privileges. I understand that my employment and/or access to certain systems may be contingent upon satisfactory results.

I authorize the background check and verification described above.

Applicant Certification

I certify that all information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that falsification, omission, or misrepresentation may result in denial of the requested services, disciplinary action, or termination of employment. I agree to comply with company policies and applicable laws in connection with the services and accesses granted under this request.

I certify and agree to the statements above.

Manager Acknowledgement (Non-signature)

Manager printed name:    Manager approval: Approved

Acknowledgement of Equipment Return and Liability

I acknowledge receipt of any equipment and access granted under this form. I agree to return all company-owned equipment, credentials, and materials upon request or upon termination of employment. I accept responsibility for reasonable care and use and understand that I may be financially responsible for loss, damage, or failure to return assigned equipment consistent with company policy and applicable law.

I acknowledge equipment return and liability terms.

Additional Notes

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