THE UNIVERSITY OF TEXAS AT DALLAS

NSERL BUILDING ACCESS AUTHORIZATION FORM

Access should be granted within 24 hours of receipt of form.
Verification will be emailed to the Contact Person. The form will be returned if not properly completed or approved.
LAST NAME

EXT

FIRST NAME

DEPARTMENT / SCHOOL / DIVISION

CONTACT
PERSON
NETID

CONTACT
PERSON
NSERL BADGE
NEEDED?

FACULTY

UTD-ID

COMET CARD #
M/S RL10
(5/6 digit number on back of card)
Initial
Contact
Person: _____________ M/S
EXT
STUDENT
GRADUATE
STAFF
OTHER
CLASS LEVEL:
UNDERGRADUATE

Door Clearances Requested (See NSERL building guide)

SPONSOR AND LAB OWNER APPROVAL REQUIRED FOR NSERL DOOR ACCESS
SPONSOR
DATE:

EXT

(Typed Name of Sonsor)

SIGNATURE:

EMAIL

LAB OWNER
DATE:

EXT

(Typed Name of Lab Owner)

SIGNATURE:

EMAIL

ACTIVATED ______________________________________ BY __________________________________________

DE-ACTIVATED ___________________________________ BY _________________________________________

o A secured box will be provided in the NSERL building mail room (1.902) for signed forms.
o Signed forms can be emailed to Wallace Martin (wmartin@utdallas.edu) or Dave Stimson (dxs098000@utdallas.edu via
encrypted email or sent via campus mail (RL10).