ID Badge Request Form

Employee ID Badge Request Form
Name
Date

MonthDayYear
Date
Department
Job Title
Employment Status (FT, PT, Seasonal)
Date of Hire
Type of card: Reason for replacement
Type of card: Reason for replacement

NewLost/Stolen/DamagedReplacementExpiredDepartment changeJob title changeName changeWear and tear
I, (type name below), am aware that replacement of a lost, stolen or damaged ID and/or Key Fob is subject to a fee of $5. Any replacement due to wear and tear, job title change, department change, and/or name change will not be assessed a fee. Upon termination, retirement or suspension, all IDs must be turned into your supervisor. The ID card policy, which includes the responsibilities of card holders, can be found in the Town of Burgaw Personnel Policy.
Full Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Employee ID Badge Request Form