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Information Technology Services Office

Application for Restricted Access VPN Service


 

(This question is mandatory)

Type of Request

Jira case No.:

e.g. ITSD-12345

(This question is mandatory)

Name of Applicant (Staff Only):

(This question is mandatory)

NetID:

(This question is mandatory)

Contact Phone No.:

(This question is mandatory)

Purpose of Application:

Part A: Guest Information

(This question is mandatory)
Guest NetID:

Part B: Host Information

(This question is mandatory)
Web URL or Host IP address (use “,” to separate URL or IP addresses if there are more than one IP address e.g. “192.168.1.1, 192.168.1.23”):
(This question is mandatory)

 

Service Ports:

(Please select at least one service port)

Part C: Service period (No more than 6 months)

(This question is mandatory)
From:
Open date/time selector
(This question is mandatory)
To:
Open date/time selector

Endorser Information

(This question is mandatory)

Name of Department Head:

(This question is mandatory)
Email of Department Head:
(This question is mandatory)
Department:
(This question is mandatory)

Name of Department CLO:

(CLO information can be found at https://www2.polyu.edu.hk/Staff/dla_clo/clo.htm)

(This question is mandatory)
Email of CLO:
(This question is mandatory)

Contact phone number of CLO:

Note:

  1. After the form is submitted, we will send EMAIL to notify all endorsers (including department head) about your application request.
  2. We shall contact the applicant within 2 working days after receiving a properly completed form.
  3. Applicant has full responsibility to inform ITS of revoking this firewall setting immediately when it is no longer required through submitting an application by using this same registration form.

 

 
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