01.26.16 v16 www.uab.edu/onecard
This form is required to issue 1) a ONE Card to new employees; 2) a replacement ONE Card to current employees; 3) a ONE Card to
Visitors/Volunteers/Vendors; 4) a ONE Card to Temporary/Irregular employees needing building access; or 5) building keys or building
card access to existing employee. Individual is required to submit this completed form to the ONE Card Office upon issue of ONE Card
or keys. Photo ID is required.
Section I - CARD HOLDER INFORMATION (Please print or type)
ENTITY: Campus SOM Hospital HSF HS CEH VIVA OSF
Card Holder First & Last Name:
BlazerID (if applicable):
Card Holder Email Address:
Home, Mobile or Work Phone#:
Title (Visitor/Volunteer/Affiliate):
Vendor Name (if applicable):
Sponsoring Dept/Employee:
Sponsor BlazerID (if applicable):
Card Holder Signature & Date Signed:
The cardholder agrees not to duplicate nor permit duplication of the card and/or keys and will surrender the card and/or keys to a ONE Card office when
transfer or termination occurs.
Section II - CARD TYPE REQUESTED
Card Type: New Employee; Hire Date _____________ Temp Employee requiring building access; Exp Date _____________
Visitor/Volunteer/Vendor Card (includes visiting students/faculty, alumni, etc.); Exp Date ______________________
UAB Affiliate (any named contractor with a long-term onsite office location)
Replacement Card: ____lost ____ stolen ____ title/name change (_______________________________________)
Job Title / Job Code (Hospital use only)
Section III - BUILDING ACCESS REQUESTED
Access Type: Card Access (New or Existing Card) Key (multiple copies of a single key will not be issued to one individual)
Animal Area Approval:
Card Access - Building Name and Room #:
Keys - Building Name and Room #:
Section IV - UAB/UAB MEDICINE DEPARTMENT REQUESTING CARD ISSUANCE
Name of Authorized Agent (Print or Type):
Department:
Signature of Authorized Agent:
Phone: ____________
Email:
Authorizing department will pay the card fee of $15.00. List account number below:
DEPARTMENT ACCOUNT NUMBER/GL STRING
COMPLETE THIS SECTION IF KEY IS REQUESTED AND PICKED UP AT BUR 230 BY A DEPARTMENT REPRESENTATIVE
Key Received by: _______________________________________________________________________________________________
Print Name Signature Date
DO NOT WRITE IN THIS BOX - FOR PHYSICAL SECURITY OFFICE USE ONLY
Verified By ____________ Date __________
Card Number: _____________________________________
Key # _________________ Code _________ Key # _________________ Code _________
Key # _________________ Code _________
Key # _________________ Code _________ Key # _________________ Code _________
Key # _________________ Code _________
ONE Card Office Locations - Hours of Operation: 8:00 am to 5:00 pm
Russell Ambulatory Center, Room M-165, 1813 6th Ave S, 205.934.2097
Burleson Building, Suite 230, 909 18th St S, 205.934-3708
Hill Student Center, Suite 103, 1400 University Blvd, 205.934.4300
ONE Card
Access/Key Request Form
Replacement cards due to promotion/transfer/name change cannot be issued until info is processed in the system of record.