RANDOLPH COUNTY COURTHOUSE FACILITY

APPLICATION FOR COUNTY ISSUED IDENTIFICATION

COUNTY/STATE EMPLOYEES

 

 

NAME OF APPLICANT_________________________________________________

                                                    LAST                                       FIRST                                                  M.I.

 

DATE OF BIRTH__________________

 

COMPANY NAME_______________________________PHONE#_______________

 

BUSINESS ADDRESS___________________________________________________

 

 

 

Requirement at Time of Application

 

1)         Completed Application

 

 

I understand this I.D. badge cannot be loaned to another individual. I will not allow a person without a badge to accompany me through the card swipe entrances or carry unauthorized items into the courthouse. I further understand it is my duty to secure this badge, and agree to contact Security immediately at 318-6774 if lost or stolen. I understand this is a privilege, which can be rescinded in the sound discretion of the issuing authority.

 

 

 

Signature of

Applicant                                                                Date                             

 

COST:        THERE WILL BE NO CHARGE FOR COUNTY OR STATE

                   EMPLOYEE’S FOR THEIR initial CARD.

                  

                   HOWEVER THERE WILL BE A $25.00 FEE FOR A

                   DUPLICAte CARD IF LOST OR STOLEN.