Facilities Services
Temporary Access Device Request Form
Contact Information
Sponsoring Department:
Contact Person:
Phone number:
E-mail address:
Name of Guest (responsible for access device):
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:
Device Holder
Date
Facilites Services Office
Date
(*See back page for ‘Temporary Access Device Contract’.)
4/2016
101 College Street SW ♦ Valley City, ND 58072 ♦ 701 845 7701 ♦ fax 701 845 7707
www.vcsu.edu/facilitiesservices ♦ [email protected]
Temporary Access Device Contract
*To be complete upon access device pick up
Valley City State University is loaning access device to _________________________________________ who
agrees to comply with the guidelines (listed below) in checking out the below access device(s):
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
* All mention of the term "access device" within this contract will refer to the University's keys or computerized
access cards used on any approved access system at Valley City State University.
1. As per university policy, no copies are to be made of the access device.
2. The access device will only be used to carry out the responsibilities related to your business with
VCSU.
3. The access device cannot be loaned to any other person.
4. The access device must be returned immediately following the completion of your assignment.
5. Any lost or stolen access device must be reported to Facilities Services/Card Office immediately.
6. Replacement of lost/stolen access devices or failure to return assigned access devices will result in
charges to the Department sponsoring the person identified as the access device holder. Valley City
State University has set the following replacement costs for the various access devices:
a. Viking Card (key card)- $25.00
b. Room key or any other key- up to $75.00 (decided upon by Facilities Services and/or
Housing).
**The person signing this contract agrees to full responsibility of holding campus owned property.
Access Device Holder
Date
Issued By
Date
Contact Number
OFFICE USE ONLY:
Due Date
_____________________
Reminder set (Outlook)
_________________
Date returned
_____________________
Keystone
_________________
File (In Use)
_________________
Initilas
_________________
File (Completed)
7/2012