NEW ACCESS CARD REQUEST FORM

Access Card Request Form
Person Completing the form
Name of Person Completing Form

First NameLast Name
Your Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Your email
example@example.com
Reason for the form
User relationship to Buildings
Department

Other Access
Program Name
Access Cardholder Information
Cardholder's Name

First NameLast Name
Keyscan Card Number
Cardholder's Email
example@example.com
Cardholder's Job Title
Cardholder's Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cardholder's Date of Birth

MonthDayYear
This will be used as your password if you happen to set off the alarm in the building.
Upload a Passport type photo for your card, blank background please.

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Supervisor's Name
Supervisor's Cell
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor's Email
example@example.com
Building Information
Hours of Access
Buildings to Access
Area of Building to Access
Health Employee
Tenant Name

Other Tenant Name
Building for Access
Building 5
Building 7

Other
FNHA
FVAC&FSS (Xyolhemeylh) - (See Map below)
Qwi:qwelstom - (See Map below)

Other access
Building 7 - 1st Floor - (See map below)

Other
Building 7 - 2nd Floor - (See map below)

Other
Building 8

Other
Building 10

Other
SRRMC

Other Access
Building 10 SRRMC

Other access
TTML (TS’ELXWEYÉQW TRIBE)

Other Access
Stó:lō Elders Lodge
Lost or Damaged Card
Additional Comments
Please provide any other access details not identified above
Should be Empty:

Access Card Request Form