Bronco I.d. Card Authorization Release Form printable pdf download

Bronco I.d. Card Authorization Release Form

Bronco I.D. Card Authorization Release Form

(STAFF ONLY)

Foundation Employee:

Your employment with Cal Poly Pomona Foundation, Inc. requires that you obtain a photo

identification card.

Arrangements have been made with California State Polytechnic University,

Pomona, to provide Foundation employees with this ID card through their PeopleSoft Identification

Program and the Bronco Access Card Program. Certain personal information is needed in order to

issue the ID Card.

First Name: ____________________ Middle Initial _____ Last Name: _______________________

Legal First Name

Legal Last Name

Social Security Number: ____________ - ___________ - ________________

Date of Birth: _____ / _______ / ________

Gender:

Male

Female

Street Address: ____________________________________________________________________

City, State, Zip:____________________________________________________________________

Home Telephone: (________) _________ - __________________

*************************************************************

I fully understand and authorize Cal Poly Pomona Foundation, Inc., to release the information listed

above to Cal Poly University, Pomona, for the exclusive purpose of obtaining an employee ID Card. I

understand obtaining an ID card is a condition of my employment through the Foundation and will

enable me to access any benefits that may be available to me as a staff employee.

Employee’s Signature:_______________________________________

Date:_________________

RETURN THIS FORM TO FOUNDATION HUMAN RESOURCES, BUILDING 55

For Human Resource Use Only:

Date information provided to CP University _________________

Bronco No. __________________________

Employee needs e-mail account:

Yes

EE#______________

Status:

TEMP-end date ___________________________

Department _______________________

Supervisor ________________________

Notified:______________

p:gs/forms/ID Card Auth Release Form-08/2006

Bronco I.d. Card Authorization Release Form