OT Access Request Form

In accordance with IACS UR E27 Section 4.2 (IAM)

Doc ID: TAG-OT-SEP-01
Issue Date: Feb 2026
Rev: 1.0

1. APPLICANT DETAILS

Full Name / Rank:		Company:
System to Access:

2. JUSTIFICATION & SCOPE

Purpose: Maintenance, Troubleshooting, Update, or Configuration Change?
Access Level: Operator, Engineer (ETO), or Admin (OEM)?	OP ENG ADMIN
Duration: Estimated time required for the task?

3. SECURITY ACKNOWLEDGMENT

I hereby acknowledge that I will follow the vessel’s Cyber Security Policy. I will not use unauthorized USB devices, will not connect the system to external networks unless authorized, and will report any security anomalies observed during my session.

Applicant Signature:

Date:

Authorized (ETO/Ch. Eng):

Stamp & Signature

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