FITNESS CENTER LOCKER ROOM ACCESS REQUEST
Columbus Campus
Form must be completed and returned to the Columbus State Police Department. A Valid Cougar ID
must be presented when the form is dropped off. You must use your Student Email for notification.
Name: ________________________________________________ Cougar ID Number: ___________________
Please print clearly
You will be notified via email when application is completed.
Email:
EMPLOYEES ONLY Department Name
Disclaimer:
Applicant must be a currently registered student and fees must be paid in full (or on deferment) before access is granted.
Completion of this application does not guarantee access to the requested area.
Access can be denied, limited, revoked, or cancelled, at the discretion of the Columbus State Community College, with
or without prior notice to the applicant.
Access to requested area is valid for the current semester only, and during normal Fitness Center hours of operation.
Access will not be granted during semester break. A new form must be completed in person each semester.
Allow ten business days after receipt by the Columbus State Police Department for your application to be processed.
Access Guidelines
for Use:
Do not allow anyone to enter the Locker Room with you
Do not loan or share your access card with anyone, including family or friends
Failure to comply with the rules and regulations of the Locker Room or Columbus State Community College may result in the
revocation of privileges. If your card is lost or stolen, or if you notice any suspicious activity, please notify the Columbus State
Police Department immediately at 614-287-2525.
My signature below acknowledges that I agree to abide by the Access Guidelines stated above. I further agree that I will abide by
the rules and regulations of the Columbus State Community College Fitness Center as they may apply to the issuance and use of
this access card.
Signature Printed Name Date
Police Department Use Only
ID Card Verified Yes _____ No _____ Verified by _________ Date Received/Verified ___________________
Employee verification Approved ______ Denied ______
Current Student Yes _____ No _____
Current Fees Paid Yes _____ No _____
Information Verified By _______________
____________________
Application approved/denied and email notification sent on ______________ (insert date)
Sent by __________________
Initials Only
Application approved and forwarded for activation on __________________ (insert date)
Card Programmed on _________________ (insert date)
STUDENTS ONLY
Address: ______________________________________________ City: _____________________________
State: ______ Zip Code: ________ Contact Phone: ______________ Secondary Phone: ______________
Applicant is soley responsible for access card and its use and/or abuse
click to sign
signature
click to edit
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