DEPARTMENT      	DATE      

KEY REQUEST / RECEIPT
(SUBMIT SIGNED CARD TO FACILITIES OPERATIONS, SB#1 ROOM 1311)

PRINTED NAME      	

PHONE #      	KEY FOR BUILDING      	

ROOM #      	KEY NUMBER      

DEPARTMENT MANAGER APPROVAL SIGNATURE

SUPERINTENDENT APPROVAL SIGNATURE

MUST BE SIGNED BY 
Chief or Deputy Chief of Central Services

ALL KEY REQUEST FOR DHMH MUST HAVE A PCA CODE      

(YOU WILL BE NOTIFIED WHEN YOUR KEYS ARE READY FOR PICK-UP, YOUR KEYS WILL BE) 
(ISSUED AT 301 W. PRESTON STREET, ROOM 1311)

I, UNDERSTAND. ACKNOWLEDGE RECEIPT OF THE KEYS DESIGNATED ABOVE. I ALSO AGREE NOT TO LOAN.
TRANSFER. GIVE POSSESSION OF, MISUSE. MODIFY OR ALTER THE ABOVE :KEYS. I FURTHER AGREE NOT TO
CAUSE, ALLOW OR CONTRIBUTE TO THE MAKING OF ANY UNAUTHORIZED COPIES OF THE ABOVE KEYS.
1 UNDERSTAND AND AGREE THAT VIOLATION OF THIS AGREEMENT MAY RENDER ME RESPONSIBLE FOR
THE EXPENSE OF A RELOCK FOR THE AFFECTED AREAS. I ALSO UNDERSTAND AND AGREE THAT A REPEAT
OFFENSE MAY RESULT IN FURTHER DISCIPLINARY ACTION BEING TAKEN AGAINST ME.

PERSON RECEIVING KEY: 	DATE RECEIVED ON

 (PLEASE DO NOT SIGN REQUEST UNTIL KEY IS RECEIVED)

MDH 4572 (Revised 10/17)