Name: ______________________________________________ Date: _____/______/_____

(please print)

Company/Univ. Dept: __________________________________________________________

Email: ________________________________ Phone: ________________________

Choose a 4-Digit Entry No._______________ ______________________________

Employee Signature

Company Agreement

I, _____________________________ (print clearly), an officer (or Human Resource Officer) of the above company, do hereby give permission for the above named employee of our company to have building access via the biometric fingerprint reader. Upon termination of employment, you will be provided the employee name and identification number to be removed from the biometric reader.

__________________________________________________________ ____/___/_____

Signature and Title (date)

Remove Employee

The above named employee is no longer employed with our company and should be removed from the Biometric Fingerprint Reader.

_______________________________________________

Signature and Title (date)

CRC USE ONLY:

Entered by: ________ Date________

Removed by: ______ Date _______