Updated 07-24-18
KEY REQUEST FORM
Date:______________
Last Name:___________________________ First Name:____________________________ Title:____________________
Employee Status (circle one): Administrator
Faculty Adjunct Staff Other:_______________
Department/Area: ____________________________________________________ Phone Ext. #: _________________
Key(s) Type: ________New ________Replacement ________Lock Change
Key(s) requested:
Key Code:_______Building:__________Room/Office Description:____________________ Master Key (Describe):____________________
Key Code:_______Building:__________Room/Office Description:____________________ Master Key (Describe):____________________
Key Code:_______Building:__________Room/Office Description:____________________ Master Key (Describe):____________________
Key Code:_______Building:__________Room/Office Description:____________________ Master Key (Describe):____________________
Key Code:_______Building:__________Room/Office Description:____________________ Master Key (Describe):____________________
APPRO
VED: _________________________________________________ Date:____________
Direct Supervisor
AUTHORIZED: ______________________________________________ Date:____________
President / Vice President
KEY HOLDER’S AGREEMENT
By my signature below, I agree to all the following terms:
1. The key(s) described herein remains the property of Glenville State College.
2. The key(s) is entrusted to me – I will not duplicate, loan, exchange, or otherwise allow use or possession by anyone
else.
3. I will report loss, theft, or destruction of key(s) immediately to Public Safety, Physical Plant, and my supervisor.
4. If the key(s) become lost, stolen, or not available for return, I will pay the key replacement fee at $50.00 per key
and/or the cost for re-keying all affected locks.
5. I will return the key(s) to my supervisor, Vice President, or the Director of Physical Plant immediately upon my
resignation, retirement, or termination of employment.
Key
holder’s Signature
(upon receipt of key(s)):__________________________________ Date of issue:____________
RETURN KEY(S) TO PHYSICAL PLANT
Key(s) accepted by (Please print):_____________________________________________ Date accepted:___________
Sig
nature:______________________________________
Key(s)
accepted by
(Please print):_____________________________________________ Date accepted:___________
(Supervisor, Vice President, or Physical Plant Director Only)
Sig
nature:______________________________________
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signature
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