---------- --, 2003 AD-1370.1A
AD-1370.1 A ---------- ---, 2003
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: | ||||||||||||||
01 Isaac Delgado Hall 02 Student Services Center 04 Weiss Allied Health Center |
08 Classroom Building 09 Community Outreach Class. Bldg. 10 Francis E. Cook Building |
22 Technology Building/ Post Office 23 Student Life Center 36 Community & Workforce Devpt. 37 O’Keefe Administration Bldg. |
| 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 | Executive Dean/Vice Chancellor | Date | |||||||||||
| (as applicable) | ||||||||||||||
| _____________________________ | ________ | _____________________________ | ______ | |||||||||||
| 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 (5/12) | ||||||||||||||
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