VPN Authorization Request
The ___________________________________________ (department, division, program) of the
Colorado School of Mines has an agreement with ___________________________ (give
company and/or individual names) for activities related to the mission and goals of the Colorado
School of Mines. Fulfillment of this work requires network access from off-campus to resources
protected by the CSM border firewall and hence requires access to the CSM VPN.
Contact information for CSM employee making the request:
Contact information for company or individual who will be using the VPN account:
If this is a company, please list the names of all individuals who will use the account

Brief description of the nature of the work to be performed, including a detailed list of the
campus resources to which access is required. If this is associated with a Mines Helpdesk
Support Request, please include the SR # also.

Effective dates:
Starting Date:
Ending Date:

Certifications: External Entity
By my signature I certify that I understand and agree to the following conditions:

Throughout the term of this agreement, I agree to use Colorado School of Mines
resources for the sole purposes described above and in the best interest of the institution.
I agree to abide by all applicable policies, procedures, rules, and regulations of the
Colorado School of Mines, including Campus Computing, Communications, and
Information Technologies (also known as CCIT), and web resources related policies and

I acknowledge that access to, and authorization to use, this service, may be terminated by
Colorado School of Mines at any time at its sole discretion.

I have read and understand the restrictions regarding the sharing and export of strong
encryption technology. I affirm that I am legally allowed to have the software, and I will
abide by any and all national and international laws regarding encryption.

Any and all computers on which the VPN client software will be installed are managed
with industry standard best security practices including but not limited to regular
application of operating system and application software patches, anti-virus software
installed and running with current virus definition files. It is CSM’s policy to terminate
immediately connection to any system believed to be infected with a virus or worm.

I will inform CSM if anyone with access to the VPN account described in this document
leaves the company or of any other event that suggests a password change is needed.

Certifications CSM Contact
By my signature I certify that I understand and agree to the following conditions:

The work to be performed by the contractor is related to the goals and missions of CSM
and is consistent with all CSM policies and procedures.

I have authority to grant access to the resources that will be used by the contractor.

I agree to inform the department of CCIT if the account is no longer needed before the
expiry date on the front of the this document.

For the purpose of CSM network and computer use policies, I acknowledge that I am the
responsible party1 for any network activity that results from the use of this VPN.

None of the guests for whom I am requesting access are under the age of 18.
1 Many of CCIT’s acceptable use policies refer to a “responsible party”; the person who has ultimate responsibility for network
traffic associated with a particular system. By requesting a VPN account for an entity not associated with the school, the
requestor assumes the role of responsible party relative to these policies. In most cases this means that you have the ability and
the authority to require the contractor named in this agreement to adhere to CCIT’s requests for information or actions. For
example, CSM receives copyright infringement notices from record companies when they believe a computer is participating in
illegal music sharing. When CCIT receives such a request, we require a letter from the “responsible party” stating that they do
not and will not share illegal files. By agreeing to fill the role of “responsible party”, CCIT would expect that you could obtain
such a letter from the contractor associated with this request, or that you would be willing to write and sign the letter on their