Employee ID: Page 1 of 1
Campus Site: Department:
Seminole State College
Safety & Security Department
PROX CARD AUTHORIZATION FORM
Requester: Date:
Please Print: Last Name First Name
Department: Position Title:
Employee Status: Full-time Part-time Adjunct: Non-employee IsPhoto Taken: Yes or No
Please Circle One
Supervisor’s Name: Supervisor’s Signature:
Campus Address: Ext. Email:
VP Printed Name: VP’s Signature:
***Please Note*** Vice President Signature Needed for Exterior Doors Access
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Building Item/Room Date Issued Signature Date Returned Signature
Approved By: Date Received:
Director of Safety & Security
Prox Card Request Form 20 Rev 02/10