Boston University Medical Campus
Information Technology

DNS or IP Request

1. Fill out the information on-line and press the submit button at the bottom of this page.
2. Print the form, fill it out, and fax it to (617) 638-6498.
3. Print the form, fill it out, and mail it via interdepartmental mail to:

   Boston University Medical Campus

   Office of Information Technology

   Help Desk – IP Address Request

   Crosstown, Fourth Floor

Last name of requestor:

Phone Number of requestor:

First name of computer owner:

Last name of computer owner:

Email Address:

Phone Number:

Department Name:

Location of Computer:

Room Number Where Computer Is Located:

Computer type:

OS type:

Wall Jack Number:

Hostname requested:

Ethernet Address:

Briefly Explain the Purpose of This Request: