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Dutchess Community College SUNYCard Authorization Form INSTRUCTIONS Individual completes Cardholder Information section. Authorizing Office completes the remainder of the form. If this is a replacement card or a Community Borrower card you must pay a 5. 00 fee. When the form has been completed and authorized take the form receipt if fee is paid and photo identification to the Security Office S-114 where you will be issued your SUNYCard. Cardholder Information Address SUNYCard Status Staff/Administrator Name Type of Card Authorized please circle one see below for Authorizing Office Expires On Permanent Full-time Faculty Adjunct Faculty City / State / Zip Credit-Free Instructor Identification Credit-Free Student Telephone Driver s License Alumnus Driver s SSN Community Borrower 5. 00 fee required AUTHORIZING OFFICE ONLY SECURITY OFFICE USE ONLY Authorizing Staff Member Card Issue Date SUNYCard Number Ext. Date Issued By Original SUNYCard Authorizing Signature Replacement Card Authorizing Office Human Resources Academic Affairs Community Services Library / Academic Services. 00 fee. When the form has been completed and authorized take the form receipt if fee is paid and photo identification to the Security Office S-114 where you will be issued your SUNYCard. Cardholder Information Address SUNYCard Status Staff/Administrator Name Type of Card Authorized please circle one see below for Authorizing Office Expires On Permanent Full-time Faculty Adjunct Faculty City / State / Zip Credit-Free Instructor Identification Credit-Free Student Telephone Driver s License Alumnus Driver s SSN Community Borrower 5. Cardholder Information Address SUNYCard Status Staff/Administrator Name Type of Card Authorized please circle one see below for Authorizing Office Expires On Permanent Full-time Faculty Adjunct Faculty City / State / Zip Credit-Free Instructor Identification Credit-Free Student Telephone Driver s License Alumnus Driver s SSN Community Borrower 5. 00 fee required AUTHORIZING OFFICE ONLY SECURITY OFFICE USE ONLY Authorizing Staff Member Card Issue Date SUNYCard Number Ext. 00 fee required AUTHORIZING OFFICE ONLY SECURITY OFFICE USE ONLY Authorizing Staff Member Card Issue Date SUNYCard Number Ext. Date Issued By Original SUNYCard Authorizing Signature Replacement Card Authorizing Office Human Resources Academic Affairs Community Services Library / Academic Services. 00 fee. When the form has been completed and authorized take the form receipt if fee is paid and photo identification to the Security Office S-114 where you will be issued your SUNYCard. Cardholder Information Address SUNYCard Status Staff/Administrator Name Type of Card Authorized please circle one see below for Authorizing Office Expires On Permanent Full-time Faculty Adjunct Faculty City / State / Zip Credit-Free Instructor Identification Credit-Free Student Telephone Driver s License Alumnus Driver s SSN Community Borrower 5. 00 fee required AUTHORIZING OFFICE ONLY SECURITY OFFICE USE ONLY Authorizing Staff Member Card Issue Date SUNYCard Number Ext.

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