VLSB Bridge / Connector Access Authorization Form

The following information is required to obtain card key authorization for access from the Life Sciences Addition into the Valley Life Sciences Building via the first floor connector and/or the fifth floor bridge. This does not authorize access into the LSA unless otherwise noted. Bring information below to Richard Forrest, 1005 VLSB, x2-4560.

Access Information

Justification:

__ Animal Use

__ Chemical Transport

__ Radioactive Transport

__ Other (specify) ____________________________

Name ____________________________

Title ____________________________

Department ____________________________

If you are not assigned within VLSB, please identify your affiliation and sponsor:

Lab/ Research group affiliation ____________________________

VLSB Faculty sponsor ____________________________

The undersigned agrees to the terms and conditions stated in the Life Sciences Complex Key Policy and the VLSB Access Policy (attached.) Failure to observe the terms of this agreement are subject to the revocation of these access privileges.

Name ____________________________

Date ____________________________

Signature ____________________________

Card Key # ____________________________

Approval Signature ____________________________

Access Code ____________________________