UNIVERSITY OF COLORADO AT DENVER AND HEALTH SCIENCES CENTER
ELECTRONIC SECURITY DEPARTMENT
BUILDING/AREA CARD ACCESS APPLICATION
INSTRUCTIONS
-Review general information about available card access levels for the building/area for which you desire access.
-Review the list of access approvers to determine the appropriate approver.
-Complete a separate application for each building/area to which you desire access and send it to the appropriate approver.
I. APPLICANT INFORMATION
Name
(First, Middle, Last):
Department/School:
(enter data in this column)
(enter data in this column)
Office Phone
Number:
Cell Phone
Number:
Pager Number:
Company/Agency:
E-mail Address:
Home Phone
Number:
If you are a member of one of the groups below, enter your ID Number(s) in the applicable box(s) below.
HSC
UCH
UPI
UCCENT
If you are not a member of one of the above groups, complete these fields.
Last four digits of Soc. Sec. No. or Passport
STUDENT
Digits for month and day of birth
II. LOCATION FOR WHICH CARD ACCESS IS REQUESTED
Building:
Tower:
Floor:
Door Numbers:
Area Description:
III. ACCESS TYPE
Permanent
Temporary
End Date:
IV. ACCESS TIMES (List days of the week and hours for which access is requested)
V. NAME OF THE ACCESS LEVEL YOU ARE REQUESTING (If known)
VI. ACCESS JUSTIFICATION
Explain why you need access to this area. Do you work for the department in charge of this area? Are you a student or intern
working on an experiment or project in this area? Provide specific information.
VII. REFERENCES
List name, position, department and contact information of HSC employees who can attest to your need for access.
W:\Card Access Application.RC1 Access Application.doc
Rev. 11/0905