TIS Department of NYSPI- ONLINE REQUEST

VPN Request Form:

Please note this: once you submit the form, your supervisor will receive an automatic email asking for a confirmation. Please type in your supervisor's full name and email address correctly. Your request will NOT be processed until your supervisor approves your request.

Upon supervisor's approval, the case will be logged into the CASESENTRY Help Desk System and your supervisor will receive a case number. To check on the status of your request, please contact your supervisor.

Items with * are required.

Requested by: (If requested by a third person) *
Requestor's email address: *
First Name: *
Last Name: *
Title: *
Department: * If Other, please specify:	Other:
Location: *
Work Phone: *
Work Fax: *
Employed By: *	RFMH Columbia NY State
Expiration Date:(mm/dd/yy) *
Supervisor's Full Name: *
Supervisor's Email: *
IT Person's Full Name:
IT Email Address:
Operation System: *
Reason to Request: *