SOFTWARE LICENSE COMPLIANCE CERTIFICATION FORM

Note: Form prints on legal size paper.

SOFTWARE LICENSE COMPLIANCE
CERTIFICATION FORM

Software Name

PO#

Location of the Software (is this software located in the cloud or on-premises? If on-premises, indicate Campus, Building, and Room#)

Division

Department

License Type (i.e. Enterprise, Per user, Site license, SaaS)

# of Licenses (for each software named)

Purchase/
Acquisition Date

Expiration Date (if applicable)

Cost

Transaction Class / Federal Program Impacted
(does this software impact any federal programs? If yes, please list the federal programs impacted. If no, indicate N/A)

Internally Developed? (was this software developed internally? Yes or No)

Externally Developed?
(if applicable, complete below)

Significant Interfaces (does this software interface with Banner or any other significant software applications, yes or no? If yes, please indicate all significant applications this software interfaces with?)

Vendor / Brand Name and Version (name the vendor from which your department purchased this software. Indicate which version of this software is in use)

Significant Customizations (if applicable) (did your department make any significant customizations to this software? Yes or No. If yes, what significant customizations did your department make?

Following LCTCS Policy #7.007 Software License Compliance and the Delgado Information Technology Security Policy , I certify that the above-listed software has the necessary and appropriate licensing and that this department adheres to the conditions of use stipulated in the licenses. Furthermore, I understand that failure to comply with the requirements outlined in these policies may result in sanctions to possibly include a verbal or written warning, formal reprimand noted on employee’s evaluation, disciplinary procedures up to and including termination, and/or reimbursement to the College. I also understand that misuse or negligence in ensuring software licensing requirements is a violation of the Student Judicial Code , and accordingly, students are subject to the Code’s requirements and applicable sanctions.

_________________________________ _________________________________ __________________________
Division/Department Head (Print Name) Signature of Division/Department Head Date

___________________________________ ___________________________________ __________________________
Designated Owner-Custodian (Print Name) Signature of Designated Owner-Custodian Date

rev: 8/9/22