Kuwait University
Center of Information Systems
Network Department
                     Please Read These Instructions!
1- Fill in the following fields
2- Print request form and get the appropriate approvals
3- Attach copy of your Mubarak Hospital ID and send it to information system department
DATE : 25-Jul-2024
Network Connection Request For Mubarak Hospital
To Filled By the User
* Name
First  Name                                 Midname                                   Last Name
* Civil ID.   
* Department  
* Building  
* Floor  
* Room    
* Network Socket (Cable #)          
   Email Address
* Telephone Number or Ext.    
    Mobile No.  
Chairman Approval Head Of Information Systems Approval Hospital Director Approval

TSA Director (Signature & Stamp)

To Be Filled By Support Section (TSA)

IP Address 139.141.
Supnet Mask 255.255.255.
Gateway 139.141.

To Be Filled By Network Section (TSA)

Switch Name                          
Switch Port #        
Vlan #