Facilities Services
Student Access Device Request Form
Contact Information
Sponsoring Department:
Contact Person:
Phone number:
E-mail address:
Name of Student (responsible for access device):
*Use back of form if requesting access for more than one student
Door Access Information
Building(s) to be accessed:
Room(s) to be accessed:
Start Date:
Start Time:
End Date:
End Time:
Reason for Requesting Access:
Department Chair
Date
Facilites Services Office
Date
(*Facilities Services Office will create the ‘Temporary Access Device Contract’ for each student)
4/2016
101 College Street SW ♦ Valley City, ND 58072 ♦ 701 845 7701 ♦ fax 701 845 7707
www.vcsu.edu/facilitiesservices ♦ [email protected]
Student Access Device Request (Instructional Use)(cont.)
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7/2012