THE UNIVERSITY OF TEXAS AT DALLAS
NSERL & BSB BUILDING ACCESS AUTHORIZATION FORM
Access should be granted within 24 hours of receipt of form.
Verification will be emailed to the Contact Person. The form will be returned if not properly completed or approved.
LAST NAME
EXT
FIRST NAME
DEPARTMENT / SCHOOL / DIVISION
CONTACT
PERSON
BADGE
NEEDED?* NSERL
CONTACT
PERSON
NETID
BSB
N & BSB
FACULTY
STAFF
UTD-ID
COMET CARD #
M/S
(5/6 digit number on back of card)
Initial
Contact
Person: _____________ M/S
EXT
STUDENT
GRADUATE
OTHER
CLASS LEVEL: UNDERGRADUATE
Once processed, all Badges must be picked up in 24 hrs. from the Comet Card Office. If it is not picked up within 30 days, your request will be voided by the Comet Card office.
Door Clearances Requested (See NSERL or BSB building guide)
*Make sure to list the door clearances by Name (Column A of guide). Form will be returned if only Door Numbers are listed.
SPONSOR AND LAB OWNER APPROVAL REQUIRED FOR NSERL/BSB DOOR ACCESS
SPONSOR
DATE:
EXT
(Typed or Printed Name of Sponsor)
SIGNATURE:
EMAIL
REQUIRED CHECK OUT POLICY: All building badges need to be returned upon graduation or end of employment at UT Dallas.
They must be turned over to Shannon or dropped off in the RL10 lock box for proper disposal. If not received, your account will be
charged. Initial here: _________________
LAB OWNER
DATE:
EXT
(Typed or Printed Name of Lab Owner)
SIGNATURE:
EMAIL
ACTIVATED ______________________________________ BY __________________________________________
DE-ACTIVATED ___________________________________ BY _________________________________________
o Signed forms can be emailed to Shannon Gaspard (shannon.gaspard@utdallas.edu) or Vickie Lincoln
(vickie.lincoln@utdallas.edu) via encrypted email or dropped off in person in BSB 1.102.
*PLEASE NOTE: If a previous student or user needs access to another building, they must return their previous building badge to
Shannon Gaspard before any new access can be granted.