Fill - Free fillable - Final - Badge Deactivation Request

Ph:801‐575‐2423|Fax:801‐575‐2377|P.O.Box145550,SaltLakeCity,Utah84114|slcairport.com/badging|airportaccesscontrol@slcgov.com

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OVERVIEW

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This form must be completedand submittedtotheBadging Officeimmediately upon change of badge status (lost, stolen, terminated,

resignation,oradministrativedeactivation).Thebadgemustbe returnedto theBadgingOfficewithin 24hoursof deactivation(unless

lost/stolen).Inadditiontothe$100feeassessedfora

non‐returnedbadge,companiesarealsosubjecttoa$100feeforfailuretonotify

theAirportofabadgestatuschange.

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Completetheforminitsentiretyandeitherfaxto(801)575‐2377oremaildirectlytotheBadgingOfficebyselectingthe“ClicktoSubmit”

buttonbelowaftercompletingoftheform.

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SECTION1

BADGETOBEDEACTIVATED

LastName

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FirstName

BadgeNumber

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CardNumber

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CompanyName

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Isthebadgeinpossessionofyourcompany?YesNo

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SECTION2

INDIVIDUALREQUESTINGDEACTIVATION

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Individualmustbeanauthorizedsigner.

LastName

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FirstName

PhoneNumber

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CompanyName

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EmailAddress

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SECTION3

REASONFORDEACTIVATION

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EmploymentTerminatedLostStolenAdministrativeDeactivation(IndicateReasonBelow)

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AdministrativeDeactivationDetails

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SuspensionMilitaryExtendedMedicalLeave

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Other_______________________________________________________________________________________________

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CLICKTOSUBMIT

SECTION4

ACCESSCONTROLUSEONLY

DeactivatedBy/Date

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Comments

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July2015

SALTLAKECITYDEPARTMENTOFAIRPORTS

REQUESTFORBADGEDEACTIVATION

Badge#

PersonID#

Submit Request

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