Access Pass Revocation Form
Submit this form to request revocation or deactivation of an access pass. Please provide complete and accurate information to ensure prompt processing.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Requester Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Passholder Full Name
*
First Name
Last Name
Access Pass Number or ID
*
Type of Access Pass
*
Please Select
Employee Badge
Contractor Pass
Visitor Pass
Temporary Pass
Other
Reason for Revocation
*
Please Select
Employment Termination
Contract Ended
Lost/Stolen Pass
Security Policy Violation
Other
Effective Date of Revocation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Unit
Supervisor or Manager Name
Additional Comments or Details
Submit Revocation Request
Should be Empty: