Building Access Request

All fields are required.

Your Name:                       
Your Agency or Section:
Your Email:                        
Your Phone Number:      

Permission is requested to access and/or to bring electronic equipment into a Courthouse(s) for the following purpose:

Date(s) of Service:(Ex: 10/14/2015 or 10/14/2015 - 10/19/2015)
Time(s) of Service: (Ex: 8:00 am-5:00 pm)                                       

Courthouse(s):  Wilkie D. Ferguson, Jr. Courthouse, Miami C. Clyde Atkins U.S. Courthouse, Miami James Lawrence King Federal Justice Building, Miami U.S. Federal Building and Courthouse, Fort Lauderdale Paul G. Rogers Federal Building and U.S. Courthouse, West Palm Beach Sidney M. Aronovitz U.S. Courthouse, Key West Alto Lee Adams, Sr. U.S. Courthouse, Fort Pierce
Location: (Ex: Judge X's chambers, Executive Office)
Purpose of Visit: (ex: delivery, repair, etc)                      

Vendor Company Name:

Individuals Entering and Their Clearance (Check One):
1- Name:  Background clearance completed - approved Not Cleared Six (6) month temp HSPD-12 cleared Unknown
Has a GSA ID Badge? Yes
List any Electronic Equipment:                       
List the purpose for electronic equipment:

2- Name:  Background clearance completed - approved Not Cleared Six (6) month temp HSPD-12 cleared Unknown
Has a GSA ID Badge? Yes
List any Electronic Equipment:                       
List the purpose for electronic equipment:

3- Name:  Background clearance completed - approved Not Cleared Six (6) month temp HSPD-12 cleared Unknown
Has a GSA ID Badge? Yes
List any Electronic Equipment:                       
List the purpose for electronic equipment:

4- Name:  Background clearance completed - approved Not Cleared Six (6) month temp HSPD-12 cleared Unknown
Has a GSA ID Badge? Yes
List any Electronic Equipment:                       
List the purpose for electronic equipment:

5- Name:  Background clearance completed - approved Not Cleared Six (6) month temp HSPD-12 cleared Unknown
Has a GSA ID Badge? Yes
List any Electronic Equipment:                       
List the purpose for electronic equipment:

Escorted by (Name) and Clearance (Check One):
Name:
 Background clearance completed - Approved GSA Building Manager HSPD-12 cleared Court Employee Chambers Staff Not Cleared Unknown Other
If Other:

Has a GSA ID Badge? Yes
List any Electronic Equipment:                       
List the purpose for electronic equipment:

Parking/Loading dock requested:  Yes No
Vehicle Information:

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