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SECURITY ACCESS AUTHORIZATION REQUEST *Denotes Required Field *Denotes Field to Be Filled By Authorizing Official **DATE OF REQUEST: IDENTIFICATION ONLY – NO ACCESS **TYPE: NEW CHANGE OF EXISTING REPLACEMENT – IDENTIFY: LOST, STOLEN, DAMAGED, **ACCESS DURATION: PERMANENT ACCESS (UNTIL REMOVED) LIMITED ACCESS FROM TO ACCESS RECIPIENT INFO: *LAST NAME: *HEIGHT: *FIRST NAME: WEIGHT: MIDDLE INITIAL: *EYE COLOR: * EMPLOYEE ID *HAIR COLOR: *DEPT/DIV or ORG: *SEX: *TITLE/ROLE: POLICE ID (If applicable): *PHONE OR EMAIL: CARD# (Filled out by IT): **ACCESS REQUESTED: CARD KEY ALARM CODE **BUILDING(S): MUNI FPSB PUBLIC WORKS PARKS SHOP UNION STATION BIC MT OGDEN JUSTICE COURT GOLDEN HOURS COMMUNITY SERVICES AMPHITHEATER 4TH ST BALLPARK MARSHALL WHITE ALARM CODE FOUR DIGIT PIN NUMBER (CHOSEN BY INDIVIDUAL RECEIVING ACCESS) NOTE: Alarm code CANNOT be "1234" "5555" "4321" etc... **EMPLOYEE CLASSIFICATION: FULL-TIME OR AUTHORIZED PART-TIME EMPLOYEE AUTHORIZED CONTRACTOR OR OUTSIDE AGENCY (FIRE, POLICE, ETC.) TEMPORARY, SEASONAL, OR VOLUNTEER OTHER. PLEASE SPECIFY: **REASON FOR ALLOWING ACCESS: **SIGNATURE OF INDIVIDUAL AUTHORIZING ACCESS: **PRINTED NAME: **TITLE*: *DIVISION MANAGER, DEPARTMENT HEAD, CAO, MAYOR, OR COUNCIL EXECUTIVE **NOTE: If recipient is meant to have identical access to existing employee, please specify the full name of existing employee: Otherwise, please specify which buildings/rooms the recipient will require access to. MUNICIPAL BLDG FRANCOM PUBLIC SAFETY PUBLIC WORKS JUSTICE COURT FLOOR ACCESS FLOOR GEN HRS AFTER HRS FLOOR GEN HRS AFTER HRS FLOOR GEN HRS AFTER HRS EMP GENERAL ACCESS (BUS HOURS) FIRE #1 – ADMIN BLDG #1 – OPS PROSECUTOR’S OFC AFTER HRS ACCESS: FIRE #2 – BATT CHIEF BLDG #1 – OPS OFFICE JUDGES CHAMBERS FLOORS 1-3 GEN FIRE #3 – CAPTAINS BLDG #1 – WATER CREW HALLWAY/JURY ADD 4TH FL ELEV. FIRE #4 – FIREFIGHTER BLDG #1 – WATER OFFICE CLERKS OFC W/COMP RM POLICE #1 – ADMIN BLDG #6 – FACILITY CREW BAILIFF ADD 5TH FL + ELEV. POLICE #2 – LTS BLDG #8 – MECHANICS HOLDING AREAS ADD 6TH FL + ELEV. POLICE #3 – SGT/PATROL BLDG #8 – PARTS JANITORIAL ADD 7TH FL + ELEV. POLICE #4 – RECORDS BLDG #8 – ADMIN ADD 8TH FL + ELEV. DISPATCH JANITORIAL ADD 9TH FL + ELEV. SWAT ADD 10TH FL + ELEV. COMM TECH AMPHITHEATER ADD + ELEV. WATER SITES ADD RECORDS MAILROOM JANITORIAL ADDITIONAL ALARM ACCESS: IT OFFICE USE ONLY: AMAG ALARM CODE AVIGILON Revised 9/12/17 24/7 ACCESS * SIGN PRINT SUBMIT