ACCESS CARD REQUEST FORM

Employee’s Name     Employee ID No.  Division/Department   Office Phone  Home Phone

Please issue above employee card access BEYOND NORMAL COLLEGE HOURS  to the following  (Electronic form users-- To mark a desired box, double-click desired “” and choose “checked”):

CITY PARK CAMPUS BUILDINGS:

Additional Specific Information (Room numbers, as applicable), etc :

OTHER CAMPUS BUILDINGS (Check Campus Location):

 West Bank Campus           Charity School of Nursing Northshore         Other: 

Specify Buildings, Room Numbers as applicable:

DAYS & HOURS OF ACCESS:

College Hours        6:00 a.m. – 10:30 p.m. – 7 Days     Unlimited – 24 hours/ 7 days Limited Access (list below):

Limited Access:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Issuance of Access Card - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I understand and agree that the access card issued upon approval of this request is the property of the College and I further acknowledge responsibility and accountability for the card. I will report loss or theft of the card to Central Control Access Administrator in the Campus Police Department immediately and to my department head. I also understand that the access card is issued for my exclusive use and may not be duplicated, loaned or used to allow any unauthorized person into a controlled area. I further understand and agree that my full cooperation will be expected during any investigation concerning a security matter that might have occurred in a controlled facility during a time when my presence in the facility has been recorded by the system. I further agree to remain knowledgeable of and abide by the College’s Controlled Access policy while in possession of the card, and I understand that any violations of this policy may result in revocation of access card use and/or disciplinary action.

Employee’s Signature:  ______________________________________________  Date: __________________

Approved:  _____________________________  ________  _____________________________  ______

     Division/Department Head      Date    Provost/ Vice Chancellor (as applicable)  Date

     _____________________________  ________  _____________________________  ______

     Department Access Control Manager  Date    Central Access Control Administrator  Date

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Replacement Card Issued - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I acknowledge receipt of replacement access card and the payment of $10.00 replacement fee.

Employee’s Signature:  _________________________________________    Date: _________________

Approval Signature:  _________________________________________    Date: _________________

       Division/Department Head          

Form 1370/002 (5/10)

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