REQUEST FOR PROPOSALS RFP NUMBER: 0A1031 DATE ISSUED

SUPPLEMENT EIGHT
FACILITY ACCESS REQUEST
NON-ODPS EMPLOYEE
ODPS SPONSOR INFORMATION (ODPS employee responsible for individual requiring access)
OHIO DEPARTMENT OF PUBLIC SAFETY SPONSOR NAME
SPONSOR DIV/SECTION/UNIT
SPONSOR SIGNATURE
X
REQUEST ACCESS BE GRANTED TO (building/location)
TYPE OF ACCESS:
REASON FOR ACCESS
COMPANY OR AGENCY INFORMATION
COMPANY NAME
ADDRESS
CITY
PICTURE IDENTIFICATION BADGE WITH ACCESS
RIGHTS
SIGN IN AND SIGN OUT/VISITORS BADGE
EMERGENCY OFFICE PHONE #
( ) -
COMPANY SIGNATURE (i.e., Corporate Officer, Chief)
X
INFORMATION ON INDIVIDUAL REQUIRING ACCESS
LAST NAME
PRESENT ADDRESS
FIRST NAME
CITY
PRINT NAME
STATE
SPONSOR PHONE #
( ) -
START DATE / /
END DATE / /
ZIP CODE
FULL MIDDLE NAME
STATE
ZIP CODE
DATE OF BIRTH: (MM/DD/YY)
SOC. SEC. #
/ /
ALIASES AND/OR MAIDEN NAME
HOME PHONE #
( ) -
YOUR SUPERVISOR’S NAME (print)
SUPERVISOR OFFICE PHONE #
( ) -
LIST ANY FELONY OR MISDEMEANOR CONVICTIONS IN THE PAST TEN YEARS AND DATE OF CONVICTION:
DRIVER LICENSE #/STATE ID/PASSPORT (ATTACH COPY OF LEGAL PICTURE ID)
I
SIGNATURE
X
,CERTIFY THAT ALL OF THE ANSWERS AND STATEMENTS ON THIS FORM ARE
COMPLETE, TRUE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ARE
MADE IN GOOD FAITH.
DATE
SUBMIT TO YOUR SPONSOR 30 DAYS PRIOR TO ARRIVING AT THE SITE. SPONSOR WILL COORDINATE THE
ISSUANCE OF AN ODPS ID BADGE.
DPS 0166 3/08