Template:Range block inquiry/doc

Usage
Administrators creating an account which bypasses a range block should as a courtesy at least, and also to obtain feedback from the blocking administrator, notify the blocking administrator consult with them. It is extremely important to keep a record of such accounts and monitor them as you may very well have created an account for the vandal or disruptive editor whose activities resulted in the range block.

Obviously to use the template you must first edit it to plug in the account name and IP range.