Security Access & ID Card Request Form

APPLICANT DETAILS
First Name

Surname

Position
Division

Service

Location
Vehicle Reg.

Phone Contact

)
CMDHB Staff
Consultant
Interpreter
Student
Contractor: Company Name
Other Specify
REASON FOR ACCESS & ID REQUEST (CHECK BOX )
New Appointment - Start Date:
Non-Permanent Expiry Date:
Expired Card
Change of Position or Title
Damaged Card
STATUS (CHECK BOX

Temporary Staff
Volunteer

Change of Name
Lost or Stolen Card

Other/Reason:

EMPLOYEE ACKNOWLEDGMENT
PLEASE NOTE A COPY OF YOUR STAFF PHOTO WILL BE HELD ON YOUR ELECTRONIC PERSONNEL FILE FOR
IDENTIFICATION PURPOSES

Signature

Date

ID CARD PHOTO SESSIONS

Venue: Security Services, Room 19, Old CCU Corridor, Middlemore Hospital
Days: Monday Friday. Time: 08.00am 12.00pm. Phone Ext. 9156 for further information

AUTHORISATION
Manager
Department/Service

RC Code

Managers Signature

Date

SECURITY USE ONLY

ID Card Issued By:

Date

The following terms and conditions apply to the use of the Access and ID Card:
1. All swipe cards and ID cards remain the property of CMDHB and will be returned to the Security Office on the final day of
employment.
2. Loss or theft of swipe cards will incur a replacement fee.
3. The swipe cards and ID cards are official documents issued under the provisions of CMDHB Security Services and relates to the
identity of the person described.
4. Impersonation of the authorised holder of the ID or swipe card, or its alteration, destruction or transfer to another person will

result in disciplinary action.