Request Date:

Person to whom key/card access priviledge is to be issued:

Name:

Department:

Email Address:

Phone #:

Account #:

Justify in detail need for key and/or lock change:

1. Maintain security of any keys issued.
2. Report the loss/theft of a key(s) immediately to Security, submit a new key request form for replacement and pay for lost key.
3. Return all University keys, upon transfer/termination, to the locksmith shop at physical plant.

Department Head Signature: