Key/Lock Request

Your Name: Date:
Your Department: Ext:
Your Building: Your Room #:

Requesting KEY/LOCK for:
 W.O. #
Key Owner Name: Ext:
Key Owner's E-Mail Address:
Key works in Building: Room #:
Key Code (If Known):
NOTE: If keys are lost or stolen, an Incident Report must be filed with Security at x1111. If Security decides the locks must be changed, the Department will be charged $65 per lock.
Request:
Reason (Why - New Hire etc.)
 
Department Head Authorization:

(sign here)
Keys can be picked up at security in B/L-13. You will be emailed when they are ready.


Key Agreement: I, the undersigned, acknowledge receipt of the key(s) designated above.  I also agree not to loan, transfer, give possession of, misuse, modify or alter the above key(s).  I further agree not to cause, allow or contribute to the making of any unauthorized copies of the above key(s).

I understand and agree that violation of this agreement may render my Department responsible for the expenses of a relock for the affected areas.  I also understand and agree that a repeat offense may result in further disciplinary action being taken against me.
Printed Name:
Signature:
Date:
Fill Out Form Then Print Page   
(Fax signed Approval form to Facilities Management at X3019)

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