|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.|
|Reason (Why – New Hire etc.)|
|Department Head Authorization:||
|Keys will be delivered to the Requestor/Key Owner.|
|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.
|Fill Out Form Then Print Page
(Fax signed Approval form to Facilities Management at X3019)