REMOTE ACCESS REQUEST FORM
Section 1 End User Information: State Employee Non-State Employee
End User's Last Name First Name
Sponsor Agency/Division* EIN # (If ADOA Employee)
Email
Phone Number
Address to ship to (Required):
I acknowledge the applicable State of Arizona policies, including: https://aset.az.gov/resources/policies-standards-and-
procedures, sections 8280 Acceptable Use, 8320 Access Controls, and 8340 Identification and Authentication.
End User’s Signature Date
ection 2 Agency Sponsor Section - Remote Access Request(s) and Authorization
Please make your selection(s):
VPN Account TACACS (For technical staff only, must also be approved by EIC staff)
PON: (Requ
ired) SubPON:
Sponsor
Agency Address:
ADD VPN Account
Token Type:
Soft Token: (User must select a soft token to be delivered electronically)
Hard Token (User must select a hard token/FOB)
CHANGE VPN Account
Details:
DELETE VPN Account
For hard token users, please provide the serial # of the token:
You may m
ail the token to Centurylink/AZNet II, 20 East Thomas, 6
th
Floor, Phoenix, AZ 85012, or ask an AZNet II
Technician to return them for you.
I acknowledge that I am responsible for notifying the AZNET Support Desk if the end user listed above transfers to
another agency, terminates employment, or no longer requires the Remote Access account(s). I also acknowledge
that, in the event of a VPN account being deleted, I am responsible for retrieving the Hard Token from the User, or
validating that this User did not have a Hard Token to retrieve.
Authorizing Agency Sponsor Name Authorizing Agency Sponsor Signature Date
Sponsor Agency - E-mail the completed form to AZNET Support Desk at AZNetSupportDesk@AZDOA.gov.
*If your agency is not listed, contact the AZNet Support Desk at 602-364-4444 or AZNetSupportDesk@azdoa.gov.
