Indian Affairs Technology
Waiver Request Form
This Document Contains Controlled Unclassified Information (CUI)
Version 1.0 (Revised 10/09/2015)
The Indian Affairs Technology Waiver Request Form is used for requesting a waiver for unapproved or non-standard technology.
Requestor’s Information
Name: Title:
Organization/office: Phone:
Address:
City: State: Zip code:
Machine name: Number of users: (list additional machines in the table below)
IT Product Information
Product name: Estimated cost:
Brief product description (e.g., manufacturer, version, and functions):
Justification
Provide a brief explanation to justify using this specific product:
Certification
To the best of my knowledge, the product above will enhance the Program’s ability to perform our function. I understand that by
signing this form it does not automatically authorize use or procurement of this requested product.
Click the signature marker to digitally sign this document and send it via email to the appropriate Federal Supervisor (do not scan this
form and sign it manually—scanned or manually signed forms will be rejected).
Requestor’s Signature Date
Approvals
Approved: Yes No
Requestor’s Supervisor
Use the following table if this waiver applies to more than one user:
click to sign
signature
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signature
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