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10.16a Access Device Sign Out Form

Name: _____________________________________________________

 

Building (circle one):      DFE        PHS        PJHS        RES        RMS

 

Key fob / card swipe card number: ______________________________

 

Key number: _______________________________________________

 

By signing this form, I take responsibility for the access devices under my care.  If lost, I agree to pay $25 for replacement.

______________________________          ____________________________

Signature                                                                Date

10.16a
04/11/2006
Rev. 05/09/2006

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