Submission Date  04/27/2018    *Requested Date   

Device Name   Cost Center

Brief description of what device supports

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New Install (Please complete entire form that will appear when you select this option)

Removal - List IPS (Please proceed to Submit Button)

Name Change

Current Name
New Name
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Location 
 North Data Center (CT)   4230 Data Center (BSC) Bellevue Medical Center (BMC) CSN-UNL
  Other 

Server Function       
 Academic   Academic/Medical Shared   Administrative  Medical Research

Equipment Type

Model

Inventory Tag #

Virtual Server
 N/A   New Server   Change from physical to virtual server  Physical to VMWare

Comments: 

Rack Mounted 
Yes (Specify # of U’s)  
No, specify dimensions
       Width  Depth  Height

Power Requirements
Number needed  
 110-20 amp   220-30 amp  Other 

Nic/Mac Address    Number needed 

Nic 3 Address Nic 4 Address

IP Address Number Needed

    Ethernet          Yes (If Yes, Number needed) 
                           No (specify) 

    Network Speed     10   100  Gig 10 Gig           Full   Half   Auto 

    Redundancy       Redundancy/Fault Tolerance  Teaming   Load Balancing

     Fiber
      No   Yes (If Yes, number needed)     LC to LC  LC to SC

     Comments:
    

     ILO   No   Yes (If Yes, specify ILO nic and network)   
                                      10   100   Gig             Full   Half  Auto

     *KVM / DSView   USB   PS/2   None

     *Network Monitoring   No   Yes

     DMZ Required (Device will be accessed from outside sources) 
     No  Yes

     Warranty/Maintenance Information     
     Begin Date  End Date 

Application Contact

Workstation Contact

User License Limit