Permit Request • CampusOptics

Requester

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Lock Owner’s Department* Required

Name of Lock Owner* Required

Name of EHS Department* Required

Necessary to reenergize before removal?* Required

If "Yes" to previous question, explain why

Document Reason for Removing Lock* Required

Attempts to contact lock owner* Required

Verify lock will be removed* Required

Verify supervisor has reviewed equipment* Required

Lock Removed By* Required

Date & time of removal* Required

Verify lock owner informed* Required

Signature* Required

Add files to upload as supporting documentation along with your permit request.

Files