Fillable Electronic Card Key Request Form2

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Electronic Card Key Request Form2

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The Electronic Card Key Request Form2 form is 1 page long and contains:

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  • 11 check-boxes
  • 19 other fields

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File type: PDF

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CARD AND KEY REQUEST FORM
*Germantown Campus – GTFacilitiesHelpDesk@montgomerycollege.edu, Rockville Campus – RV-Lockshop@montgomerycollege.edu,
Takoma Park/Silver Spring Campus - TPFacilitiesHelpDesk@montgomerycollege.edu
Form Instructions:
1. Fill out all fields.
2. Print the form and have the department manager/chair sign the form.
3. Scan the form and email the completed form to the Facilities Helpdesk or Lockshop at your respective campus.
(See below for contact information*)
Note:
A. If the completed form is emailed from the manager/chair, no signatures are required to process the request.
B. Hand written or hard copy forms will not be accepted.
C. All forms must be emailed.
Point of Contact Email:
Date of Request:
REQUESTOR INFORMATION:
Name:
(Last Name)
(First name)
(MI)
M#:
Position:
FT
PT
Temporary
Non-employee
Campus:
Office Phone: Department:
Requesting:
Swipe Card (GT/RV only)
Prox Card
Key
Additional Access
Replacement
If this is a replacement, is your card:
Lost/ Stolen
Damaged/ No longer working
Areas needing access: (ex. CC101, SA203, ST205, etc…)
Requestor’s Printed Name:
Requestor’s Signature:
Date:
Manager/ Chair’s Name:
Manager/Chair’s Signature:
Date:
Montgomery College Key/Card Agreement
In return for the loan of this key/card, I agree: 1) not to give or loan the key/card to others; 2) not to make any attempts to copy, alter,
duplicate, or reproduce the key/card; 3) to use the key/card for authorized purposes only; 4) to safeguard and store the key/card
securely; 5) to immediately report any lost or stolen keys/cards; 6) produce or surrender the key/card upon official request; 7) to
return the key/card to Security if/when I move offices, relocate to another campus, or leave the College. I also agree that is the
key/card is lost, stolen, or not surrendered when requested a charge that reflects the cost of changing any and all locks affected may
be assessed.
Requestor’s Signature: Date:
**Facilities/Security Use Only
Officer/Staff Sign-off:
Date notified Requestor:
KEY/CARD INFORMATION: (check all that apply)
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Electronic Card Key Request Form2

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Completed 4 April 2020

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