14-Attachment No. 12 REQ-0006631 GLWA Access Request Form.pdf

• Legal Name: Enter name as shown on your Driver's License

• Employee/Contractor: Select a value from the drop-down list

• GLWA Group: Select a value from the drop-down list with the primary Group

• Assign Primary Work Location: Select a value from the drop-down list

• Email Address: Enter your GLWA/Contractor email address

• Home Address: Enter your own home address as shown on your Driver's License

• Ceridian Employee No.: Enter your Ceridian ID if you are an Employee

• Vehicle Info: Enter Year, Make, Model & Plate of your primary vehicle

• Company Name/ Contract No. & Name: Enter your company name, contract number and name if you are a Contractor.

Instructions for the Security & Integrity Access Card Request Form

The Security & Integrity Access Card Request Form initiates the process for Security & Integrity to set up and provision access badge card requests. This form is to be used for either Employee or Contractor and only one person at a time. All fields are mandatory unless indicated as Optional or do not apply as an Employee or Contractor.

Section 5: Approvals Signatures are required. Ensure the LTM or Project Manager have signed the form (electronically or manually). Security & Integrity will sign the form once you email them the completed form and copy of your Driver's License (front and back) at badges-request@glwater.org.

• Access Start and End Date (Optional): Use the calendar to indicate the start and end date to access the facility. End date is Optional for Employees but should be used for a Contract End Date for Contractors. Access will expire for Contractors after 1 year.

• Attached Copy of Driver's License: Check the box indicating you are attaching a copy of your Driver's License to the request. This is required for every request; no access will be provisioned without a copy of a valid Driver's License.

• Badge Renewal (Optional): Check the box to indicate access renewal is needed.

Contractor badges automatically expire annually (if not requested prior) from date of issue and require renewal using this form.

• Additional Access Request (Optional): Check the box indicating that this request is one for additinoal access than

• Driver's License No. Enter your current valid Driver's License no.

• State/Province: Enter your state/province as it appears on the Driver's License

• Access Locations Needed (Optional - see Copy Access from Team Member): Check one or more of the boxes. Fill out the Other text box if the facilities are not included as a checkbox.

• Gates/Doors (Optional - see Copy Access from Team Member): Enter All the Gates/ Doors you need to access (or enter in "All Gates/Doors" if applicable)

• Access Times (Optional - see Copy Access from Team Member): Enter the expected times needed of facility access (ex. M-F 6am-6pm)

• Copy Access from Team Member (Optional - see Access Locations Needed, Gates/ Doors, and Access Times): Enter a team member's name in this box to copy access in lieu of providing the details of Access Locations Needed, Gates/Doors and Access Times fields.

Section 2: Team Member Emergency Contact Info Provide the name of your preferred primary emergency contact name and phone numbers.

Section 3: Leadership Team Member (LTM)/ Project Manager (PM) Info Provide the LTM (if Employee) or PM (if Contractor) name, email address & phone no.

Section 4: Team Member Access Request

Section 1: Team Member Info mailto:badges-request@glwater.org

SECURITY & INTEGRITY

ACCESS CARD REQUEST FORM

Revised: 1/14/2021

This form initiates the process for Security & Integrity to set up and provision access badge requests. Please submit completed form to badges-request@glwater.org.

Legal Name (as shown on Driver's License) Employee/Contractor*

Assigned Primary Work Location

GLWA Group

GLWA/Contractor Email Address

Section 1: TEAM MEMBER INFO:

Section 2: TEAM MEMBER EMERGENCY CONTACT INFO:

Primary Phone No.

Ceridian Employee No. (if Employee)

Vehicle Info (Year, Make, Model, Plate)

Home Address (Street Address, City, State, Zip Code)

Company Name / Contract No. & Name (if Contractor) Leadership Team Member/Project Manager

LTM / PM Date

Date

Section 3: LEADERSHIP TEAM MEMBER (LTM) / PROJECT MANAGER (PM) INFO:

*Contractor badges automatically expire annually (if not requested prior) from date of issue and require renewal using this form.

Access End Date*

LTM / PM Email

LTM / PM Phone No.

Emergency Contact Name Primary Phone No. Secondary Phone No.

Section 5: APPROVALS:

Section 4:: TEAM MEMBER ACCESS REQUEST:

OR: Copy Access from Team Member

Security & Integrity

Badge Renewal*? Additional Access Request?

Access Start Date

Attached Copy of Driver's License?

Driver's License No.

State/Province

Gates/Doors (separate items using commas)

Access Times (e.g. M-F 6am-6pm ; 24/7)

LHP NEP SPP SWP WBB

WRRF WWP

Access Location(s) Needed:

Other(s) mailto:badges-request@glwater.org