Building Security Request Form

Building Security Request Form

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

Cancelof

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