Remote Access Agreement by WoodyWoodcock

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									                                   Remote Access Agreement
                            For NW Social Service Connections HMIS

I, ________________________________ (Name), am applying for Remote Access Authorization for
NWSSC HMIS.

I require remote access for the purpose of:




Location/Site for remote access:                                        IP Address:

Dates/Times for remote access:

My ServicePoint Login is:

Agency:                                          Program(s):

I certify that I have read the Remote Access Policy, I am and will be in compliance with all Policies,
Procedures, Agreements and rules associate with NWSSC HMIS.

Signature:                                                               Date:


As Agency Administrator I have reviewed this application. I find it is a valid and active request. I support
and approve this application for Remote Access. I understand that it is my responsibility to assure the user
is in compliance with this and all other Policies, Procedures, Agreements and rules associate with NWSSC
HMIS. I may audit remote access by associating dates and times to the user’s time sheet.


Signature:                                                               Date:



System Administrator
Signature:                                                               Date:




NWSSC12                                                         NWSSC HMIS Remote Access Agreement Page 1 of 1
                                                                                      Legal Review 08/02/2006
                                                                                          Released 09/05/2006

								
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