IP Address Request - The University of Akron

IP Address Request Form

Please complete the following form to request an IP Address.

*Denotes required fields

Enter E-mail Address (Where IP Address will be sent): *

Date of Request: *

EQUIPMENT INFORMATION:

Make: *
Model No.: *

Type (i.e.: Printer, Server, Computer, etc.): *

EQUIPMENT LOCATION:

Department Name: *

Building: *

Room No.: *

RESPONSIBLE PERSON:

Name (First, Last): *

Phone No.: *

Office No.: *

REQUESTOR INFORMATION (If different from Responsible Person):

Name (First, Last):

Phone No.:

NUMBER OF IP ADDRESSES: (If you require more than one IP Address and all of the information above is correct for each address needed, please fill in the number required below. If the information above is different for each IP Address, you will need to send separate requests.)

Number of IP Addresses: *

If you have any questions or comments, please type them below.

We appreciate all your comments!

Thank you for your input!

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The University of Akron is an Equal Education and Employment Institution.

Last modified: February 22 2005 16:33:16