For Office Use Only
Faculty and Staff
ID Card Application
UVA ID Card Office
UVAID LCC #: ______ Oracle: ______
Date: ____________________________
Done By: _________________________
CavAdv
9//99
Cash
Check
PTAO
Revised: 11/08/16
Today’s Date: ___/___/___
Be Prepared to Present an Original Valid Government Issued Photo ID
Reason for Application: (Circle ONE Reason Only)
New Employee
Wage Employee
Lost ID Card
Worn ID Card
Current Employee
without ID Card
Visiting Employee
Stolen ID Card
Change of Name
Non-UVA Employee
Damaged ID Card
Other
Retired ID Card
Expiration Date Required:
____ ____ ____
No Charge
Fee Charged
$15 Replacement Fee
Payable by cash, check
or PTAO#:
Payable by cash, check,
Cavalier Advantage or
PTAO. NO credit or
debit cards.
__ __ __ __ __ __ - __ __ __
__ __ __ __ __ __ __- __ __ __ __ __
No Charge ONLY if
Current ID Card
Returned
DO NOT punch a hole in your card or bend it! Keep entire card protected!
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 # __ __ __ __ - __ __ __ __ __
Date of Birth: ____/____/____
(NOT Oracle # or Social Security #)
(We can look up UVA ID #)
UVA Computing ID: ______________________
Department Name: _______________________________________ Building: ____________________
Employee Status:
___ Full Time UVA Employee (receiving benefits)
___ Part Time UVA Employee (receiving benefits)
___ Part Time UVA Employee (not receiving benefits)
___ Retired UVA Employee
___ Foundation UVA Employee
___ Other
I certify that the information on this form is correct and that my request for a UVA Employee ID card is in accordance with the
appropriate circumstances. I recognize that all UVA ID cards are the property of the University of Virginia and are provided to
affiliated persons for appropriate identification use. It is valid so long as I continue my affiliation with the University. Upon
separation, the card must be returned to the appropriate department.
_____________________________________
Employee Signature
Supervisor Name: ______________________________________ Telephone: _____________________________
Supervisor Signature: ___________________________________ (Benefits counselor signature may be substituted.)