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
Add a new Access CardChange AccessReplace Lost or Damaged CardDelete Access
Employee of Stó:lō Service Agency (INCLUDES PROGRAM RELATED CONTRACTORS)Building TenantContractor (PROVIDES SERVICES TO OPERATIONS)
FINANCEOPERATIONSSTÓ:LŌ HEALTH SERVICESSASETSRRMCOther 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.

Cancelof
Supervisor's Name
Supervisor's Cell
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor's Email
example@example.com
Building Information
Monday - Friday (07:00 - 17:00)Monday - Friday (06:00 - 22:00)Monday - Sunday (06:00 - 22:00)Monday - Sunday 24 / 7
All BuildingsIndividual Buildings
Common Area Access OnlyAll Building AccessSpecific Office Access (provide details in Additional comments below)
ASCD / AIDP AccessDaycare AccessDental AccessJustice AccessNurse AccessStó:lō Elders LodgeOther Health Access
Fraser Health AuthorityFNHAFRAFCAFVAC&FSSStó:lō Community FuturesTs'elxwéyeqw TribeSardis PharmacySerenity ChiropracticFraser Valley Child Development CenterOther Tenant Name
Building 1ABuilding 2ABuilding 2BBuilding 2CBuilding 2DBuilding 5A/BBuilding 7Building 8A/BBuilding 9Building 10Building 11Building 19 / 26Mission - St. Mary's CampusStó:lō Elders LodgeMaintenance CompoundVehicle CompoundOperations ShedEvents Shed
Side Door (East Side)1st Floor East Door SASET2nd Floor West Door5A/B Door5B Main Door
Common AreasGym Access (Waiver needed)Other
Building 5a accessBldg. 7, Office 243Bldg. 7, Office 244Bldg. 7, Office 245Bldg. 7 BasementAll FNHA Access
Office 217Office 218Office 219Office 220Office 221Office 222Office 223Office 224Office 225Office 226Office 227AOffice 228Office 229Office 230Office 231BasementAccess to All offices
Office 211Office 212Office 213Office 214Office 215Office 216Office 247Office 248Access to all officesBasementOther access
Office 101Office 102Office 103Office 104Office 105Office 106Office 107Office 108Office 109Office 110Office 111Office 112Office 113Office 114Office 115Office 118Office 119Office 120Office 121Office 122Office 134Office 135Office 136Office 137Office 138Exam 140Exam 141Store room 142Exam 144Exam 145Exam 146Exam 147New Exam 1New Exam 2Other
Office 200AOffice 200BOffice 203Office 204Office 205Office 206Office 207Office 208Office 216Office 232Office 233Office 235Office 239Office 241Office 242Other
Building 8ABuilding 8BOther
Common AreasOther
ArcheologyVehicle CompoundStorage Shed in CompoundBuilding 10 Specific AccessBuilding 10 Common AreasTourismOther Access
LibraryArchive RoomClassroom External DoorPublic RepositoryArcheology LabArcheology Lab External DoorOffice 201Office 204Office 205Storage 208Office 210Office 211Office 212Office 213Office 214Office 215Office 216Office 218Office 219Office 220Office 221Office 301Office 302Office 303Office 304Office 305Other access
Office 310Office 311Office 312Office 313Office 314Office 315Office 317Office 319Office 321Store room 322Office 323Basement StorageOther Access
Suite 101Suite 102Suite 103Suite 104Suite 105Suite 106Suite 107Suite 108Suite 109Suite 110Suite 111Suite 112Suite 113Suite 114Suite 115
Card is Damaged and does not work (Need card Returned)Card is misplaced and lost (To Replace a Lost card there is a $25.00 Fee)
Additional Comments
Please provide any other access details not identified above
Should be Empty:

Access Card Request Form

Person Completing the form

Access Cardholder Information

Building Information