REQUEST FOR ACCESS TO ROOM 41
Fill out completely. Print clearly.
Name:
(last, first, middle initial)
Office:
Office Phone:
Home Phone:
ID Number (11 digits):
Classification:
Physics Staff, Position:
Faculty  Staff Other:
Physics Graduate Student:
Signature of Major Prof/Advisor:
Undergraduate Student:
Signature of Major Prof/Advisor:
Reason for needing access:
The applicant must have a legitimate need to access the Faculty Shop. The card access issued to
the applicant is for the sole use by the applicant. The doors to rooms 40 and 41 must remain closed
and locked at all times.
It is against University regulations to loan or give your Purdue identification card to anyone
else to gain access to the Faculty Shop.
Persons loaning their ID cards, or allowing anybody access (for any reason) into the Faculty
Shop could have their shop privileges revoked. As well you must adhere to the Shop
Procedures/ Shop Safety Guidelines to retain your shop right of entry.
Faculty Shop hours are 7:30am – 4:00pm, Monday thru Friday.
Signed:
Date:
/
/
------------------------------------------------------------------------------------------------------------------------------------------For Staff Use Only
Faculty Shop Procedures and Safety Guidelines Date:
Hazcom Training Date: _____ /
Approved:
/
/
/
Date:
/
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