11/9/2017 10:55:46 AM
Authorized by (print or type): _________________________________________________________________
(Note: You cannot authorize your own request)
Authorized Signature: ____________________________________________ Date: ______________________
(Dean, Director, or Supervisor
WASHTENAW COMMUNITY COLLEGE
The Public Safety Department
ELECTRONIC ACCESS PROX/FOB REQUEST FORM
To be issued to* (print or type name):________________________________________________________________
Last First M. I.
Full Time □ Part Time □ Job Title__________________________________ WCC @ ID # ___________________
Washtenaw Community College Work Phone _______________________________________
Department______________________________ Org. # ____________ Bldg/Office/Room# __________________
In order to process request promptly and be notified of its completion, please be sure to fill out
this form completely.
A photo on file is required for processing prox card requests. Please visit SC 264 to have your
picture taken/saved on file.
It normally takes six (6) days to process and make FOB/Prox Card. Every effort will be made to notify you when the
FOB/Prox Card are ready—be sure to fill in a WCC work phone number. FOB/Prox Card may be picked up at the Public
Safety Office in the Parking Structure, Room CS205. Please bring a current picture ID.
College FOBs/PROX cards are not to be loaned, transferred, or duplicated. If lost, promptly file a
report with the Public Safety department at 734-973-3411.
Forward all requests to Public Safety, CS 205
Electronic Access FOB - PROX Card -
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Public Safety Department Use Only KEY NUMBER: K-__________________
EMPLOYEE NUMBER: ______________
Meets Procedure Guidelines: Yes □ No □ Initials:____________________
If No, please give reason: _____________________________________________________________________
Date FOB’s/key(s) made: _______________________or date request denied:__________________________
FOB’s/Key numbers made: ______________________________________by:
__________________________
