BROWN&BUILDING&ACCESS&
AUTHORIZATION&FORM&
&
NAME:&
LAST&______________________________&FIRST_____________________&
&
Signature&of&user&requesting&Access&&_______________________________________&
&
User’s&DEPARTMENT&_________________________&
&
&
&
ACCOUNT&TYPE&(please&check&one&only)&
User&Type:&&& Chen&Ugrad&student&& ☐& Chen&Grad&Student& ☐&
& & & Chen&Faculty/Staff& ☐& Chen&Researcher& ☐&
& & & MCF&User&(24X7)& ☐& ELEN&Lab&Access& ☐&
& & & &
Other____________________________&
&
&
Supervisor&Name&(printed)&__________________________________&Phone&#&________________&
&
Signature&Authorizing&Access*&_______________________________________&
&
Access&Expiration&Date&(required)&______________________&
&
*note:&authorizing&signature&must&be&from&faculty&or&staff&–&cannot&be&a&student&
FOR&OFFICE&USE&ONLY:&
&
Date&entered:&
&
&
Entered&by:&
&
&
Access&Categories:&