Chorus Permanent

/ CHORUS ACCESS CARD APPLICATION & CHANGE FORM
Security Operations Centre, Chorus Hamilton, PO Box 9405, Waikato Mail Centre, Hamilton 3240
Phone: 0508 10 30 60, Option 3
Email:
CARD HOLDER / SUPPORTING MANAGER TO COMPLETE
Tick One / Tick One /

CHORUS PERMANENT

NEW

WORN OUT CARD

CHORUS CONTRACTOR / REPLACEMENT / DAMAGED/BROKEN CARD
CHORUS TEMP / AMENDMENT /

EXPIRED CARD

CHORUS VISITOR / CANCEL /

LOST CARD

CHORUS TENANT / /
All Fields marked with a “*” MUST be Completed for this form to be Processed.
*First Name / * Surname / *Signature
*Card Number (If Known) / *4 Digit PIN No. (New cards only) / *Contact Phone Number*
* Job Title / Chorus Employee Number
*Work Address /

*Company

*Address to post card to / *Town/City & Post Code

* E-mail Address ______

PHOTOGRAPH (A standard passport photo is required & all photos are required to be updated every 5 years)

PHOTO ON FILE OK PHOTO EMAILED (ATTACHMENT )
MANAGER SUPPORTING THIS APPLICATION: See Notes Below
1. Access approval for Chorus sites shall be in accordance with the Card Access Approval Delegations Authority chart, which is appended to the Site Access and Security Manual.
2. H&S: Everyone on any Chorus premises or working on a Chorus activity has a responsibility to keep themselves safe, to actively look out for the safety of others and to speak up early if they have any concerns
MANAGER SUPPORTING: By supporting this application you are endorsing that cardholder is competent in their role and has the necessary training to carry out their job effectively.
*Contact Number / *Designation / *Print Name / *Signature
Access Competence
To access network areas /security equipment (e.g. Cardax, MDF, Server or Switch Room) the following competencies below must be completed:
Has Applicant/Cardholder completed the PTN “Accredited Training” course/refresher within the last 24 months? YES NO / *PTN Date Completed ______
*PTN Chorus approved Trainer name: ______
Authority for Approving Access
Access Required / The person signing this form must be noted as a current Chorus signatory. (Current signatory database is held by SOC)
/ Either

Site / Building Name

Doors / Levels

/ Day
M – F
6AM TO 6PM / 24 Hour /

*Signatory Name

/ *Signature / *Designation / *Contact Number
Comments

26 June 2017 Chorus Access Card Application & Change Form Page 1