Remote Network Access Request Form

for Consultants & Contractors

* Applicant Information

ALL ANSWERS ARE REQUIRED.

 
*Provide your answers below.
Name
Title
Company
Telephone number
Remote Location
Internet Service Provider
Computer Make / Model
AV Software
AV Version
AV Datafile Version
* NJCU Liaison Information

ALL ANSWERS ARE REQUIRED.

 
*Provide your answers below.
NJCU Liaison Name
Liaison Title
Liaison Department
Liaison Telephone number
Project
Anticipated Expiration Date
* Email Addresses

ALL ANSWERS ARE REQUIRED.

 
*Provide your answers below.
Applicant Email Address
NJCU Liaison Email Address
* Are you a sub-contractor?
REQUIRED FIELD.




Please contact the IT Help Desk (helpdesk@njcu.edu) if you require any assistance.  
Thank you.