Software Whitelisting Request Form

1. Requestor Information
Name
Title
Department
Date of Request

2. Program Information
Program Name
Executable Path
Version Number
Hash Value (MD5)
Purpose of the Program
Scope/Directories the Program Will
Process/Work On
Timing of software execution
Business Justification for Whitelisting
*Attach quarantine alert screenshot

3. Review by Cybersecurity Operations Team

Form Completeness Verified Yes / No
Documentation Completeness Verified Yes / No
Risk Assessment Conducted Yes / No
Summary of Risks Identified
Potential Security Threats Analyzed Yes / No
Summary of Security Threats
*Attach Antivirus Quarantine Report

3. Decision
Decision Approved / Denied
/ Request Additional Information
Reason for decision

Reviewed by
Title
Date
Signature