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.
Reason (Why – New Hire etc.)
Department Head Authorization:

(sign here)

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.

Printed Name:
Fill Out Form Then Print Page   
(Fax signed Approval form to Facilities Management at X3019)