RANDOLPH COUNTY COURTHOUSE FACILITY
APPLICATION FOR COUNTY ISSUED IDENTIFICATION
COUNTY/STATE EMPLOYEES
NAME OF APPLICANT _________________________________________________
LAST FIRST M.I.
DATE OF BIRTH __________________
COMPANY NAME _______________________________ PHONE# _______________
BUSINESS ADDRESS ___________________________________________________
Requirement at Time of Application
1) Completed Application
I understand this I.D. badge cannot be loaned to another individual. I will not allow a person
without a badge to accompany me through the card swipe entrances or carry unauthorized items
into the courthouse. I further understand it is my duty to secure this badge, and agree to contact
Security immediately at 318-6774 if lost or stolen. I understand this is a privilege, which can be
rescinded in the sound discretion of the issuing authority.
Signature of
Applicant Date
COST: THERE WILL BE NO CHARGE FOR COUNTY OR STATE
EMPLOYEE’S FOR THEIR INITIAL CARD.
HOWEVER THERE WILL BE A $25.00 FEE FOR A
DUPLICATE CARD IF LOST OR STOLEN.
