Firewall Exemption Letter

Originator * Date
* Agency
* First Name
* Last Name
* Email
* Telephone No

Request

I would like a firewall exemption for the following IP addresses and applications. My agency has compensation access controls which identify and authenticate all users.

* IP Addresses include

* Computer Application(s)

* My agency has its own firewall authentication procedures
uses a secure private network
other alternative procedures

If Other State Here

Information * Please state the purpose and business need for the exemption request

* Please give a brief description of the business process associated with this exemption request

Name of Agency IT Representative (please print)

___________________________________________________________

Signature of Agency IT Representative

___________________________________________________________