Employee Identification Badge/ Access ... - State of Louisiana
Jay DardenneCommissioner of AdministrationJohn Bel EdwardsGovernorP. O. Box 44001 D Baton Rouge, Louisiana 70804-4001 D (225) 219-4800 D 1-800-354-9548 D Fax (225) 219-4810An Equal Opportunity EmployerOffice of State BuildingsState of LouisianaDivision of AdministrationContractor Access Card Enrollment Form OSB Badging Office’s Telephone Number: (225) 219-4799 Email Badging.Office@ or Fax the completed and signed forms to (225) 219-9309Access Cardholder InformationContractor’s First Name: FORMTEXT ?????Last Name: FORMTEXT ?????Date of Birth (mm/dd/yy): FORMTEXT ?????La. Driver License No.: FORMTEXT ?????Company’s Name: FORMTEXT ?????Company’s Address: FORMTEXT ?????Company’s Phone Number: FORMTEXT ?????Supervisor’s First Name: FORMTEXT ?????Last Name: FORMTEXT ?????Supervisor’s Job Title: FORMTEXT ?????State Agency InformationAgency: FORMTEXT ?????Department: FORMTEXT ?????Building Name: FORMTEXT ?????Telephone (work): FORMTEXT ?????Building Access Code(s) & Access Time(s)Building Access Code(s): FORMTEXT ????? FORMTEXT ?????Access group name(s) must be listed.Time of Access: FORMTEXT ????? FORMTEXT ?????(ex. Office hours Monday-Friday, 24 hours 7 days a week, etc. Access times must be listed.Signature RequirementAuthorized Agency Rep. Signature:Date:Printed Name: FORMTEXT ?????TEL No.: FORMTEXT ?????For Internal Use Only – Please do not mark in this areaIssued Access Card No.Processed ByDateCONTRACTOR’S NAME: FORMTEXT ?????Jay DardenneCommissioner of AdministrationJohn Bel EdwardsGovernorP. O. Box 44001 D Baton Rouge, Louisiana 70804-4001 D (225) 219-4800 D 1-800-354-9548 D Fax (225) 219-4810An Equal Opportunity EmployerOffice of State BuildingsState of LouisianaDivision of AdministrationDuration Period Expected to Perform WorkPlease indicate and mark “X" on one of the following: FORMCHECKBOX One Month FORMCHECKBOX Three Months FORMCHECKBOX Six Months FORMCHECKBOX Other** **If Other, provide justification below: FORMTEXT ????? FORMTEXT ?????Purpose of Work to Be Performed by Contractor: FORMTEXT ????? FORMTEXT ?????Federal Equal Employment Opportunity Law RequirementsThe State of Louisiana requests the data below so that we may comply with Federal Equal Employment Opportunity Law Requirements.Ethnic Origin: FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Non-Hispanic or Non-Latino Race: FORMCHECKBOX White FORMCHECKBOX American Indian/Alaskan Native FORMCHECKBOX Native Hawaiian or other Pacific Islander FORMCHECKBOX Asian FORMCHECKBOX Black or African American FORMCHECKBOX OtherGender: FORMCHECKBOX Male FORMCHECKBOX Female Place of Birth: FORMTEXT ?????REQUIREMENT FOR SUBMITTAL:All two (2) pages must be completely filled out for badge to be issued. The completed forms must be submitted to OSB ID/Badging office via email to Badging.Office@ or via fax to (225) 219-9309. ................
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