Building Security Request Form

Building Security Request Form

For questions, contact the Human Resources Director of Risk Management at 763-450-5008
Select Role*

EmployeeManagementHuman Resources
Employees:

Select Employee to report your lost, stolen, damaged, or nonfunctional badge. For any other requests, please contact your Supervisor to complete the form.

Supervisors:

Select Management if you are a Supervisor filling out this form for an to update an Employee's access, an Employee's PIN number, or an Employee's personal information.

Employee
Type of Change*

Report a lost or stolen badgeReport a damaged or nonfunctional badge

Management
Type of Change*

New hire or rehire accessModify existing accessRequest a new PINName or position Change

Employee Information

Please enter the information for the employee in which this security notice is for
Company*
Employee Legal Name*

Legal First NameLegal Middle NameLegal Last Name
Employee Preferred Name

First NameLast Name
Employee Email
example@example.com
Current Location*
Current Program or Department*
Current Position *
Badge Number (first 5 numbers on the back of the ID badge)
Effective Date of Change*

MonthDayYear
Date
Supervisor Legal Name*

Legal First NameLegal Last Name
Supervisor Email*
example@example.com
Does the Employee's badge photo need to be updated as part of this request?*

YesNo
Badge Photo *

Cancelof

Separation
Select security change type*

Remove all security access on the effective dateRemove all security access effective immediately
Effective Date of Change*

MonthDayYear
Date
Comments

Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Person completing the form*

Legal First NameLegal Last Name
Email of person completing the form*
example@example.com
Signature*

Clear
Date of Signature*

MonthDayYear
Date

Employee