1. ACCESS CARD REQUEST FORM
      2. CITY PARK CAMPUS BUILDINGS:
      3. DAYS & HOURS OF ACCESS:

---------- --, 2003 AD-1370.1A
 
 
AD-1370.1A ---------- ---, 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
05 Joey Georgusis Center
06 Martin Hall
 		07 Thames Hall /Library 
08 Workforce Development/ Continuing Ed
09 Workforce Development

10 Francis E. Cook Building
  		11 Michael L. Williamson Complex 
22 Technology Building/ Post Office
23 Student Life Center
37 O’Keefe Administration Bldg.



 
 
Additional Specific Information (Room numbers, as applicable), etc:
OTHER CAMPUS BUILDINGS (Check Campus Location):
West Bank      Charity Sidney Collier Site   Jefferson Site 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 DateExecutive Dean/Vice ChancellorDate
(as applicable)
_____________________________ _____________________________________ ______
Department Access Control Manager DateCentral Access Control AdministratorDate
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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 (11/17)

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