Request For Public Ip Address And/or Domain Name Service Registration Form

Request For Public Ip Address And/or Domain Name Service Registration Form - Wvde

Request for Public IP Address and/or Domain Name Service Registration Form

West Virginia Department of Education (WVDE)

Directions: Please complete this application to request a public IP address for your network device and/or to

signatures. You must attach the appropriate School, County or RESA Acceptable Use Policy defining

support responsibilities for these services.

Local or LAN IP Address of Server: 10._____._____._____

Date: __________________

Public IP Address: 168.216.____.____ (to be assigned by WVDE)

(Please review information on Intranet planning process at

for assignment of 10. address for server.)

Physical Location of Network Device (Circle one):

School

County

RESA

Other: (explain)_____________________________________________________________

Location Name: ____________________________________________________________

Address: __________________________________________________________________

City/State/Zip: ____________________/___________/_____________________________

Phone: _______________________________Fax: ________________________________

Room #/Location: ___________________________________________________________

Purpose:

Is this an official school or county network device? Yes

If no, please explain: __________________________________________________________

How will this network device be used? (Explain purpose/services/protocols/ports used.)

___________________________________________________________________________

Operating System of network device (if applicable): __________________________________

Is a Domain Name or URL required for this device? Yes

Technical Contact (Responsible adult for the server):

Name: _______________________________ Title: ______________________________

Email: _______________________________ Location Phone: _____________________

Home Phone: _______________________

Location Name: ____________________________________________________________

Address: __________________________________________________________________

City/State/Zip: _______________________/_______________/______________________

Administrative Contact (principal, superintendent, other):

Name: _______________________________ Title: ______________________________

Email: _______________________________ Location Phone: _____________________

Home Phone: _______________________

Location Name: ____________________________________________________________

Address: __________________________________________________________________

City/State/Zip: _______________________/_______________/______________________

Request For Public Ip Address And/or Domain Name Service Registration Form - Wvde