For Office Use Only
Contracted Employee
ID Card Application
UVA ID Card Office
UVAID LCC #: ___________________
Date: ________________________
Done By: _____________________
CavAdv
9/2/99
Cash
Check
PTAO
Revised: 10/06/15
Today’s Date: ____/____/____
Be Prepared to Present an Original Valid Government Issued Photo ID
Reason for Application:
_____New ID Card ($15 Charge)
_____Lost/Stolen/Damaged ID Card ($15 Replacement Charge)
_____Worn ID Card (No charge if current card returned at time of replacement.)
_____Expired ID Card (No charge if turned in within SIX months from date on card.)
Do not punch a hole in the card. If you do, and the card is damaged, there is a $15 replacement fee.
Make Check Payable To: University of Virginia (include full address and daytime phone number)
Please Print Clearly
Have you been issued any other type of UVA ID card? (Circle) Academic or Hospital (NOT health insurance card) Yes No
Name: ______________________________________________________________________________
First
Middle
Last
UVA 9-Digit ID #: __ __ __ __ - __ __ __ __ __ (NOT YOUR SOCIAL SECURITY #) (We can look up UVA ID #)
Date of Birth: _____/_____/_____
UVA Computing ID: ____________________
Company Name: _____________________________________________________________________
Project Title/Description: _____________________________________________________________
Date of Project Completion/End of Contract: _____/_____/_____
UVA Department Responsible for Contract: _____________________________________________
Building Name: _____________________________________________________________________
ID Card fee ($15) to be paid by (circle one):
Cash
Check
PTAO
PTAO#: __ __ __ __ __ __- __ __ __ - __ __ __ __ __ __ __ - __ __ __ __ __
Contracted Employee Signature: _______________________________________________________
UVA Sponsor/Supervisor Name: _______________________________________________ (Please print)
UVA Sponsor/Supervisor Signature: ______________________________ Phone: ________________