Trusted Network Certification Form Date: _______________________ TRUSTED NETWORK CERTIFICATION We will comply with the "Specifications for Networks Connected to the Administrative Information Services through the High-Speed Data Backbone". The Network Administrator will notify the Administrative Computing Security Officer when/if any changes are made to our network configuration which may compromise overall security. This includes changes in network operating system/platform. _____________________________________________ ________________________ Network Administrator Date     _____________________________________________ ________________________ Access and Security Representative Date     _____________________________________________   TCP/IP Network Address Range   **Entry of individual IP addresses or IP address ranges into the IP filter is at the discretion of the Network Administrator and Access Security Representative. If you have certified a range of addresses, please check below to let us know how you would like these to be entered into the filter: Enter all addresses from range indicated above _______ Certify the range indicated above, but enter individual addresses upon request ______

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