8-0005317.Attachment No. 7 Access Request Form.pdf
PDF 1 MB Posted
- Attached to
- 42-Inch Downriver Transmission Main Loop State and local contract opportunity
- Solicitation number
- REQ- 0005317
- Issued by
- Wayne County, Michigan
About this file
This is a Security & Integrity Access Card Request Form used by the Great Lakes Water Authority (GLWA) to manage facility access for employees and contractors. The form serves as the initial step in provisioning access badge card requests for GLWA facilities and is submitted to the Security & Integrity department at badge-requests@glwater.org. The form accommodates both employees and contractors on an individual basis and requires completion of mandatory fields including legal name, employee or contractor status, assigned primary work location, GLWA group assignment, email address, home address, driver's license information, and vehicle details. For contractors, the form requires company name, contract number, and contract name. The form includes provisions for specifying access start and end dates, with contractor badges automatically expiring annually and requiring renewal. Requesters must indicate which facility locations are needed, including options for LHP, NEP, SPP, SWP, WBB, WRRF, and WWP, along with specific gates or doors and access times required.
The form requires submission of an attached copy of a valid driver's license for every request, without which access will not be provisioned. All requests must be approved and signed by the appropriate Leadership Team Member (LTM) for employees or Project Manager (PM) for contractors before submission to Security & Integrity for final processing and signature. The form also requires emergency contact information and allows for optional badge renewal requests or additional access requests beyond initially approved permissions. The completed form, including the driver's license copy, must be emailed to badge-requests@glwater.org to initiate the access provisioning process.
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Text version
• 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 at badge-requests@glwater.org and they have completed the access request.
• 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:badge-requests@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)
| GLWA Security & Integrity Access Card Request Form-- |
| New Access Request Form_DRAFT (1) |
| Access Card Request form |
| Contractor/Consultant Name: |
| Assigned Location: [Please select] |
| Leadership Team Member/ Project Manager: Donna Spiller |
| Driver's License Copy: Off |
| Security & Integrity Signature Date: |
| Team Member Signature Date: |
| State: |
| Driver's License Number: |
| LTM / PM Email Address: donna.spiller@glwater.org |
| Access Start Date: |
| Access End Date: 10/16/20 |
| TM Email Address: |
| Employee/Contractor: [Please select] |
| Group: [Please select] |
| Badge Renewal: Off |
| Additional Access Request: Off |
| LTM / PM Phone Number: (313) 495-5357 |
| Ceridian Employee ID: |
| Vehicle Info: |
| Street Address, City, State, Zip Code: |
| Company/Contractor Address: |
| TM Phone Number: |
| Emergency Contact Name: |
| Emergency Contact Primary Phone: |
| Emergency Contact Secondary Phone: |
| Doors/Gates: |
| Access Days/Times: |
| Copy Access from Team Member: |
| LHP: Off |
| NEP: Off |
| SPP: Off |
| SWP: Yes |
| WBB: Off |
| WWP: Off |
| WRRF: Off |
| Other Location: |
File details come from the government source that posted it. Updated .