DIXIE STATE COLLEGE KEY REQUEST FORM
You are responsible for all keys issued to you until you return them to Campus Service.
Name                              Date
Print name of person receiving keys
Department Name    Work Phone #
Select One:   New Key   Replacement of Lost Keys  Contractor Other
Are the keys requested for: Permanent or Temporary Use from to
				Date                    Date
List keys needed, obtain proper signatures below and send original to the Campus Service.
		Key #1	Key #2	Key #3	Key # 4	Key #5
Building Name
Door Number
Key Type		A B C D	A B C D	A B C D	A B C D	A B C D
Key Types:    A-Individual Rooms (Classroom, Closets, Offices, Store Rooms, Gate Key)
B-Exterior Doors
C-Building Master
D-Campus Master
SIGNATURE'S REQUIRED FOR ALL KEYS:       * Deans Signature required for ALL Keys
Supervisor's Signature:________________________				Print Name ____________________________
Dept. Chair or Equivalent:______________________				Print Name ____________________________
*Dean or Equivalent:_________________________				Print Name ____________________________
SIGNATURE'S BELOW ONLY REQUIRED FOR CAMPUS MASTER KEYS:
Vice President's Signature:__________________________________________________________
President's Signature:______________________________________________________________
I have received the above keys and agree not to copy them.  I also agree to return them to the
Campus Service Office at the end of my employment.  Please refer to key policy section 81.7.1 & 2.
Signature X_____________________________________  Date___________________
For Office Use Only
Tag Number
Key Symbol
Return Verification__________________________ Date__________________________
DO NOT FAX FORM					Work Order #________________

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