UCI Math Key Form

University of California, Irvine

Key Use Authorization & Key Acceptance and Use Agreement

To be completed by issuing department/unit

Mathematics DepartmentAuthorized by The following person has been issued keys that access UC Irvine facilities:

Key Holder*

Job Title*

Department*

Email Address*

example@example.com

Specific Key request (if different than your office space)

Key Serial

Key Number

Building/Room

Print name*

Non-UCI Email Address

Date Issued

Date Returned

Key PIN Code (for pickup from Traka Key box in mailroom, RH 322. Mailroom door code is: 13579#

Key Acceptance and Use Agreement

To be completed by receiver of key(s)

For and in consideration of the use of the above listed keys to the University's premises, the undersigned hereby acknowledges receipt of such keys, and agrees to use such keys only in accordance with the UCI Key Control and Access Policy, including the requirement that University Great Grand Master and Grand Master keys shall not be taken off campus except as required by official University business, and that University keys shall be secured at all times.

In the event any University key in Key Holder's possession is lost or stolen, Key Holder agrees to report such loss or theft immediately to their unit. The undersigned agrees that the above keys remain the sole and exclusive property of the University while in the undersigned's possession and agrees to return all keys to their unit upon termination of University duties or upon one business day's prior request by the unit.

In the event the undersigned fails to return any of the keys upon termination of University duties or within one business day of request by the unit, the undersigned agrees that a key replacement fee of up to $40 may be charged by the University for each key not returned. In addition, the undersigned agrees to reimburse University the actual cost of re-keying the lock(s) and agrees that University may withhold such re-keying costs from key deposits due the undersigned. The undersigned understands that their name will be listed as the person responsible for the above numbered keys in the department's record.

Signature of person receiving key(s)*

Date*

Date

Yes

Key Use Authorization and Key Acceptance Distribution Issuing Unit Disposition: Unil individual terminates