Employee Card Replacement Form

Employee Card Replacement Form

Employee Information

Employee Name:

Employee ID:    Current Badge Number (if known):

Primary Phone:    Email:

Position Information

Department:    Job Title:

Reporting Manager:    Work Location:

Card Replacement Details

Type of Card: Proximity   Magnetic Stripe   Smart Card   Other

Lost   Stolen   Damaged   Malfunctioning   Name Change

Police Report Filed: Yes   Report Number:

Original Issue Date (if known):    Was original card returned? Yes   No

Replacement Fee Assessed: Yes   Amount:

Employment History

Title:    Dates Employed:

Title:    Dates Employed:

Education

Highest Degree:    Institution:

References

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Disclosures & Authorizations

At-Will Employment: Nothing in this form alters the employment relationship. Employment remains at-will and may be terminated by either the employee or the employer at any time, with or without cause or notice, unless otherwise provided by a written agreement signed by an authorized company representative.

Equal Opportunity: The company provides equal employment opportunity without regard to protected characteristics. This form will be processed in a non-discriminatory manner consistent with company policy and applicable law.

Authorization: By submitting this form I authorize the company and its security provider to deactivate any prior credentials associated with my identity, to issue a replacement credential, and to verify information provided herein for the purpose of access control. If my card was lost or stolen I understand that I remain responsible for reporting unauthorized access and cooperating with any investigation.

I authorize the company to contact my previous employers and conduct identity verification or background checks as necessary to validate credentials.

Applicant Certification

I certify that all information provided on this form is true, complete, and correct to the best of my knowledge. I understand that intentionally providing false information may result in disciplinary action, up to and including termination. I agree to return any found company credential to the Security Office and acknowledge that replacement fees may apply in accordance with company policy.

I certify the above statement.

Manager / Security Review (For Administrative Use)

Manager Name:    Manager Approval: Approved   Denied

Security Office Use Only - Badge Number Issued:    Date Issued:

Replacement Fee Collected: Yes   No   Amount:

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