Fillable Printable Smart Card Request Form - California
Fillable Printable Smart Card Request Form - California
Smart Card Request Form - California
Smart Card Request Form: FACULTY & STAFF FORM
First Smart Card is FREE, Replacement card(s) are $20 (payment
must be incl uded with request)
Mailing Address: Pacific Oaks College
Registrar’s Office
55 Eureka St
Pasadena, CA 91103
Telephone: 626.529.8076
FAX: 626.529.8090
E-mail: r[email protected]
Employee ID or SSN # ________________________________
First Photo ID Card Request: Yes No
Replacement Card: Yes
No
Name:
Last Name First Name Middle (FULL)
Address:
Street Number and Name
City State Zip Code
Cellular / Home: Work Phone:
Employee
E-mail Address:
Department Information:
Department _________________________________ Dept. Phone _______________________________
Supervisor Name _____________________________ Supervisor Phone ___________________________
Employee Signature Date
Special Instructions and Requirements for Students/Employees at a Distance
Employees at a distance must submit a digital photo by e-ma il only, meeting the following requirements:
1. Color portrait shot (no side or ¾ profiles) with a blank white/beige background
2. Hats or sunglasses are not allowed
3. The digital picture must be in a JPG format and no larger than 750 kb in size. Pictures not meeting the abo ve
requirements wil l not be accepted
4. Please allow two weeks from receipt of the request for the Smart Card to be mailed
Sample
Office Use Only
Issued Key Card Number: __________________________________
Registrar Initials: ____________
Date: ____________ ______
Card Mail-out Date: ________________
Facilities Initials: ____________
Date: ___________________
