Agreement to Comply With Information Security Policies

A signed paper copy of this form must be submitted with all requests for

1) Authorization of a new user-ID,

2) Authorization of a change in privileges associated with an existing user-ID, or

3) Periodic reauthorization of an existing user-ID.  Modifications to the terms and conditions of this agreement will not be accepted by [Your Corporate-name] management.

User Printed Name: ______________________________________

User Department: _______________________________________

User Telephone Number: __________________________________

User’s Office Physical Address & Mail Stop: ______________________

I, the user, agree to take all reasonable precautions to assure that [Your Corporate-name] internal information, or information which has been entrusted to [Your Corporate-name] by third parties (such as customers), will not be disclosed to unauthorized persons.  At the end of my employment or contract with [Your Corporate-name], I agree to return to [Your Corporate-name] all information to which I have had access in order to do my job.  I understand that I am not authorized to use this information for my own purposes, nor am I at liberty to provide this information to third parties without the express written consent of the internal [Your Corporate-name] manager who is the designated information owner.

I have access to a copy of the [Your Corporate-name] Information Security Policies, I have read and understand these materials, and I understand how they impact my job.  As a condition of continued employment at [Your Corporate-name], I agree to abide by these information security policies.  I understand that non-compliance will be cause for disciplinary action up to and including system privilege revocation, dismissal from [Your Corporate-name], as well as criminal or civil penalties.

I agree to choose a difficult-to-guess password as described in the [Your Corporate-name] Information Security Policies document, I agree not to share this password with others, and I agree not to write the password down unless it has been transformed in an unrecognizable way.

I also agree to promptly report all violations or suspected violations of information security policies to the Director of the Information Security Department (at xxx-xxx-xxxx).

User Signature & Date: ____________________________________

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