Last Name

First Name

Title

Faculty Host/Advisor

Office Address

Email Address

Home Address

Home Phone

Date Arrived at Statistics Department

Expected Departure Date

Key for Room #1

Key for Room #2

Key for Room #3

Key for Room #4

Key for Room #5

**EMPLOYEE COMPLIANCE ACKNOWLEDGMENT**

NOTE FROM UNIVERSITY KEY POLICY (SY-19)


A nonredundable key replacement fee will be charged to ALL University key holders for lost University keys. In addition, actual recoring costs, which could be several hundred dollars, may be charged (if deemed appropriate by the budget executive) as a result of such lost keys .

All keys referred to in this policy are the property of The Pennsylvania State University and are not to be duplicated by any faculty, staff, or student. Duplication of a key, or possession of a duplicate key, will result in referral to the Office of Conduct Standard or the Office of Human Resources for appropriate sanctions.

Upon termination of employment and/or student status or transfer from the area, all keys must be returned to Laurie Roan, in Room 326 Thomas Building. Failure to return keys upon termination or transfer may result in the holding of employee accounts or a charge to a student account until the keys are returned, or the cost of recoring the facility is recovered.

I have read the above. In accepting keys from the Key Custodian, I agree to comply with the terms specified above and all related University policies.