Clearance Request Form

This form is used by authorized facilitators to request card access/clearance from the NSU PSD Security Operations Center.

Note: All fields marked with an asterisk (*) are required.

Today's Date: *

Facilitator's Information: (You must be a pre-approved facilitator)

Name: *

Email: *

Department: *

Department Code: *

Title: *

Office Phone: *

Building: *

Room/Office#: *

Type of Request: *

Name: *

NSU N#: *

NSU Affiliation: *

Department: *

Title: *

Name of Clearance(s):

Time Clearance Should Be Active:

(i.e. 0900- 1700)

Day(s) Clearance Should Be Active:

(i.e. M-F)

Does Clearance Need to Be Active on NSU Holidays?

Yes No

Please click the "SUBMIT INFORMATION" form only once.

Please verify that you have completed all required fields and are not a robot before submitting this form.