Visitor Checkout Pass Form
Please complete this form to check out and confirm return of all issued items before leaving the premises.
Full Name of Visitor
*
First Name
Last Name
Visitor Email Address
*
example@example.com
Visitor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company/Organization (if applicable)
Name of Host or Department Visited
*
Purpose of Visit
*
Date and Time of Check-In
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Check-Out
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Visitor Pass or Badge Number (if issued)
Items Issued to Visitor (select all that apply)
Visitor Badge/Pass
Access Card
Keys
Parking Permit
Other
Have all issued items been returned?
*
Yes, all items have been returned
No, some items are missing (please specify below)
If any items are missing or not returned, please specify details
Additional Comments or Feedback
Visitor's Signature (to confirm all information above is accurate)
*
Submit Checkout Pass
Submit Checkout Pass
Should be Empty: