CITY ISSUED WIRELESS DEVICE
ACKNOWLEDGEMENT FORM
Department/Division: Date:
Employee’s Name: Position:
Wireless Equipment Description:
Reason wireless device is necessary (check all that apply):
□
Employee must conduct City business while in thefield
□
Employee has a critical need to maintain accessibility with other departments in order to insure
uninterrupted customer service
□
Employee is in a public safety position that requires immediate and directcommunication
THE CITY ISSUED WIRELESS DEVICE ACKNOWLEDGEMENT FORM MUST BE REVIEWED ANNUALLY BY THE
DEPARTMENT DIRECTOR TO DETERMINE IF THE ASSIGNMENT CONTINUES TO BE JUSTIFIED.
I have received a copy of Policy 6.03 – Telephone & City Issued Wireless Telephone Devices. I understand and agree it is
my responsibility to read and abide by the policy, and that I should consult my supervisor or the Human Resources
Department if I have questions.
I agree to use the communication systems for City business as appropriate and in compliance with the policy. I
understand that while minimal personal usage will be allowed, it must not interfere with my productivity. I know that
accessing or distributing any material that is inappropriate, offensive and/or sexually explicit will not be tolerated by the
City. All information accessed, communicated or distributed must be in compliance with all City and departmental
policies.
I acknowledge that all City communication systems are considered to be City property and may be accessed at the time
by authorized officials of the City. Employees do not have privacy rights in the use of City communication equipment
and the messages, data, access to or distribution of such material is subject to Open Records.
I acknowledge that any violation of this policy can be grounds for corrective action, up to and including termination of
my employment.
Employee’s Printed Name Signature Date
Appendix E
Form 28
Requested by:
Department Director Signature: Date
Approved by:
City Administrator Signature: Date
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
