KU School of Medicine-Wichita: Facilities Management – Card Access Request/Removal Form

Facilities Forms - Card Access Request/Removal Form

NOTE: All fields are required unless specified as optional. Use tab key or mouse to move from field to field.

There is a $3.00 non-refundable administrative fee to replace lost or stolen access cards, and payment will need to be submitted in the Facilities office located in Room B050. (Damaged or defective access cards will be replaced at no extra charge).

Payment for access cards can be made by check addressed to KUSM-W, or by cash for the exact amount, as we are not able to make change. No credit or debit card accepted.

Information

Name:

Title:

Department:

Campus Address:

Campus Phone:

Fax (Optional):

Billing Account # (Optional):

E-mail Address:

Reason:

Supervisor Information

Name:

Extension:

E-mail:

Faculty Staff Student Resident

Request Removal

Finish

Date needed (24 hours advance notice required):

Other information or comments (optional).