sProximity_Request_Form.pdf

BARC Alarm Office, Bldg 047A, Rm.105 BARC-West, 10300 Baltimore Ave., Beltsville, MD 20705

Tel: 301-504-6294 Fax: 301-504-6419

PROXIMITY CARD/SECURITY CODE REQUEST FORM

Date of Request: ___________________________

Request for: [ ] New Security Code [ ] New Prox Card [ ] Upgrade [ ] Replacement [ ] Extension of Expiration Date

(Temporary Employees)

EMPLOYEE’S FULL NAME: _______________________ ____________________________________________

(First) (Please Print) (Last)

Employee’s Building Number: __________ Room Number: __________Telephone Number: ____________________

Institute / Center / Division / Branch / Lab: ______________________________________________________________

Employee’s Immediate Supervisor’s Name: ______________________________________________________________

Supervisor’s Building Number: ____________ Room Number: ____________

Supervisor’s Telephone Number: ( ) __________ ____________

If Replacement, reason for request (include date of loss or theft if applicable):

If Upgrade requested include EXISTING CARD/CODE NUMBER: ______________________

CARD/CODE P-PERM F-FED SECURITY CATEGORY DAY ONLY ACCESS 24/7 ACCESS

FULL NAME NUMBER T-TEMP NTE DATE N-NON FED (PROX CARD ONLY) BLDGS/AREAS BLDGS/AREAS

Authorized Requesting Research Leader Printed Name Telephone Number Building Number Room Number

(REQUIRED) Authorized Requesting Research Leader Signature

ALARM OFFICE USE ONLY

Date Received: ________________________ (New) Card Number: _______________

Date Entered in Database: ______________ BY: ________ Date Card Delivered: _____________ BY: _______