IP Address/DNS Entry Service Request

Contact Name:
Contact Email Address:
Example "Jonesg"
Contact Telephone Number:
Contact Department:
Requests for: Static IP Address
Server IP Address
DNS Entry (for Website)
Other (provide information in comments box below)

Information required for a Static IP Address:

User Name:
User Email Address:
User Department:
Location of equipment:
(include building name and room number)
Wall plate Information:
Primary Host Name Being Requested:
Aliases Being Requested:
Hardware Address:
Enter the full Hardware Address, for example "00-08-22-ad-11-21".

Additional information required for a Server IP Address:

Requests for: File Server
Web Server
Database Server
Print Server
FTP Server
Security Related Questions:
1. Will this IP Address require full public access (outside of HSC firewall)?

2. Will this server store, gather, or access sensitive information? Such as:

    a. Electronic Protected Health Information (ePHI)

    b. Student Identifiable Information (SII)

    c. Personally Identifiable Information (PII)

    d. Sensitive Digital Research Information

    e. Intellectual Property

    f. Business Critical Information

    g. Payment Card Information (PCI)

    h. Other Sensitive Information

Information required for a new/to change website DNS entry:

User Email Address:
User Department:
Project ID:
Authorized Signature:
Proposed URL Address:
Primary Host Name Being Requested:
Alias Being Requested:
If IP Address exists, please provide:
Security Related Questions:
1. Will this website be accessible from the Internet?

2. Will this website need TCP/IP ports other than 443 (HTTPS) or 80 (HTTP)?

    If Yes, please include:
    Server TCP/IP Port numbers:


3. Will this website require users to login and authenticate?

4. Will blog software be utilized on this website?

If any Security Related Questions are answered as "yes," the T&N process will include a review by Information Security and/or the Webmaster.


Please note: Failure to provide required information may cause a delay in service processing.
Thank you.