Campus Card Student Badge Application
Please print
First Name
Last Name
MI
Name:
Stony Brook ID Number:
Department:
Title:
Expiration Date (MM/DD/YY):
I have certified the required patient access clearances and authorize the Campus Card Office to issue
ID cards and badges as indicated above.
Title
Authorization Signature
Date
(Signature must be on file in Campus Card Office)
Stony Brook University Card Regulations:
• The Stony Brook ID card is the property of the issuer.
• There is a replacement fee for lost, stolen or damaged campus cards.
• If your card is lost or stolen, please report it immediately to the Campus Card Office.
• The StonyBrook ID card shall not be transformed, altered or tampered with in any way.
• Campus departments may not hold the Stony Brook ID card for any reason wth the exception of University Police if
such is required in the performance of their duties.
• Campus Card photographs can be used for identification purposes in other matters of University business.
• Cardholders are advised not to lend cards to anyone.
• Hospital Access bagde status is not guaranteed by the Campus Card Office; if there is a question regarding the
badge you are to be issued, you will be referred to the appropriate office.
• The retrievable stored values on the card remain the property of the card holder.
By signing the box below, you agree to the terms and conditions listed here.
Signature
For Office Use ONLY:
SB Employee Initials
Government issued photo ID presented
q Green Card # q Drivers License # q Passport # q Other
Campus Card Office
254 Administration
631.632.2737
ASAF0003 (04/14)
_______
Date
___________
_____________________
Campus Card Office East
L3, 162 Health Sience Center
631.444.8151
www.stonybrook.edu/campuscard