Electronic Communications Acceptable Use
Remote Access Authorization
Non-exempt Personnel
Employee Name __________________________
Date of Request ________________
Department ______________________________
Position ______________________
Name of Supervisor ________________________
Date of Approval _______________
Termination Date _______________
Approved duties to be performed outside of work hours: ________________________________
______________________________________________________________________________
Is the employee authorized to use City owned/provided equipment? Yes ____ No ____
If yes, type of City owned equipment to be used _______________________________________
I acknowledge receiving a copy of the City’s Acceptable Use policy for Electronic
Communications and Internet Use, understand the policy and if given authorization will follow
the policy as outlined in the latest revision dated September 15, 2014.
_________________________________
Employee’s printed name
_________________________________
Employee’s signature
___________________
Date
Approved authorization includes access as needed for city related business and the usage of City
owned equipment if identified above.
Approval Signatures
Supervisor _________________________________________
Date _______________
Additional Approval Signatures (requires two, in addition to the supervisor above)
System Administrator ________________________________
Date _______________
Human Resources Director ____________________________
Date _______________
Administrative Services Director _______________________
Date _______________
City Administrator ___________________________________
Date _______________
A copy of this authorization will be placed in the employee’s personnel file. Any changes to the
approved authorization as stated above, will require a new request and approval.
11/10/14