Badge Request Form

Name*

First NameLast Name
Position / Title*
Are you an administrator?

YesNo
Employment Start Date*

MonthDayYear
Date
Vonage Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Email*
example@example.com
Home Office*

BEAT AIDS Headquarters (208 W Euclid, 78212)San Antonio Care Center - Five Points (230 E Fredericksburg Rd., 78212)San Antonio Care Center - Brady Gardens (2207 S Zarzamora St., 78207)Newly Empowered Women (618 Hudson St., 78202)
Birth Day / Month

Agreement
- I understand that I am required to wear my BEAT AIDS ID at all times during
  working hours including in meetings and trainings AS PART OF MY UNIFORM. (Outreach to client’s home is the exception)
- I understand that if at any time my ID is lost or stolen, I must report this to my immediate supervisor.
- I understand lost or stolen ID cards will be replace at my own expense in order to meet BEAT AIDS dress code policies.
- I understand that a $5.00 fee will be requested of me if ID is lost or stolen.
Signature*

Clear

Agreement