Security Photo I.D.
Badge Request Form
Badge Office Hours are:
Monday 10:00 A.M. to 3:00 P.M. – Wednesday 6:00 A.M. to 3:00 P.M. Friday - 10:00 A.M. to 3:00 P.M.
No Appointments are needed during the above hours, just drop in. We are closed all Holidays
For a photo ID appointment please call: (425) 261-3913 or fax your completed form to: (425)261-3920
Date:
Specify type of Photo ID below:
PEMC Hospital Employee
Medical Office Building
Providence Physician Group
Medical Staff
Volunteer Service
Providence Seattle Employees
Contractor/Vendor/Temp
Student Education
Providence Regional Employee
Has Providence Security made you a Photo ID before?
Yes
No
Employee Name:
Last name
First name
MI
BADGE INFORMATION - As you would like it to appear on your badge
Last Name (OPTIONAL)
First Name
Title on Badge
JTC Code
Cost Center#
Dept Phone #
Signature of Employee: _____________________________________
WC #: __________
CONTRACTORS VENDORS & STUDENTS COMPLETE THE FOLLOWING SECTION
Company Name:
Phone#
Address:
City,
State
Zip
For Security & Administration use
Manager/Director Signature:
________________________________________________________
Human Resources Verification:
________________________________________________________
Employee ID # ______________
Date Badge produced: ______________________________________