Fillable Form Number/Rev #: NY CREATES - SUNY Poly (SUNY Polytechnic Institute)

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Form Number/Rev #: NY CREATES - SUNY Poly (SUNY Polytechnic Institute)

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NY CREATES - SUNY Poly ID -
Access Card Request Form
Form Number/Rev #
ANT-00001-F1 R17
Printed copies are considered uncontrolled. Verify revision prior to use.
DCN1981 Confidential When Completed Page 1 of 1
SPONSOR INFORMATION
Sponsor Name:
Title:
Company:
Email Address:
Phone:
Requests must be made by Authorized Sponsors only. A list of Authorized Sponsors is updated by Access Control.
REQUESTED FOR EMPLOYEE INFORMATION
Legal First Name:
Legal Last Name:
Company:
Title:
Email Address:
Phone Number:
Country of Citizenship:
If other than the United States of America enter DOB,
Visa Type, and phone number.
Date of Birth (MM/DD/YY)
Visa Type:
Email form to Access Control at accesscontrol@sunypoly.edu . If the person is other than a US Citizen email to both Access Control and Chief
Gary Bean at Beangt@sunypoly.edu for non-citizen clearance.
ACCESS REQUESTED Check box if form is for a badge extension
EMPLOYEE’S START AND END DATES:
**If the employee is not a temporary employee, the end date should match the
assigned company term date as part of the annual renewals process.
(MM-DD-YY): From________ To________
DAYS: ☐ Mon-Fri
☐
Mon-Sat
☐
Mon-Sun
TIMES: From________ To________
☐
24 HRS
GENERAL SITE ACCESS:
Requires completion of Safety Orientation Training.
CLEANROOM ACCESS:
Requires completion of Safety Orientation and Cleanroom
Safety.
YES NO
ADDITIONAL ACCESS:
Must be submitted by the sponsor in a separate email to accesscontrol@sunypoly.edu indicating the
person(s) name and badge number requiring the access, card reader(s) being requested, and a brief
explanation as to the necessity.
Requires completion of Safety Orientation and Lab Safety Training.
Lab Room #(s)
Additional Required Training: BioSafety Laser Safety
STUDENT ACCESS:
Requires completion of Safety Orientation Training
Bio Undergrad Grad Post Doc
ACCESS CONTROL USE ONLY
TRAINING VERIFICATION:
Completed:
☐
Safety Orientation
☐
Cleanroom Safety
☐
Lab Safety Verified By: Date:
PROGRAMMED/ISSUED BY: / Card Number:
POLICY COMPLIANCE***:
***By signing above, the requestor acknowledges that they have received a copy of the NY CREATES / SUNY
Polytechnic Institute Campus Badge Identification
and Site Access Policy and that they will comply with the
policies within. The requestor also acknowledges that they understand that not following all items outlined may
result in revocation of access and the requestor will need to retake training for access to be reinstated.
Applicable Exports Control Documentation for this individual is on file with the Human Resource Dept. or
Exports Control Authority of the Sponsor’s organization.
YES NO
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Form NumberRev : NY CREATES - SUNY Poly (SUNY Polytechnic Institute)

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Completed 1 February 2021

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