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Badge Request Form
Role Selection
Role
*
Community
Employee
Employee Spouse
Student
DM Burr
Contractor
Ferris State Faculty
Ferris State Student
Michigan State Faculty
Michigan State Student
Cass County Sheriff
Dowagiac Fire Department
Dowagiac Police Department
Pokagon Band Tribal Police
Badge Recipient Information
Legal Last Name
*
Legal First Name
*
Middle Initial
*
No Middle Initial
No Middle Initial
SMC ID Number
*
ID Number Needed?
Yes
Badge Information
Request Type
*
New
Replacement
Replacement Badge Information
New Photo Taken
*
New Photo Taken
Use Existing Photo
Reason for Badge Replacement
*
- Select -
Photo Update
Lost
Stolen
Damaged-Destroyed
Name Change
Employee Title-Dept Change
Other
Unknown Discovered After ID Created
Please indicate the reason you are requesting a replacement for your SMC ID badge
Name Change Information
Please enter former name in the spaces provided below
Previous Legal Last Name
*
Previous Legal First Name
*
Previous Middle Initial(s)
*
Other Details
Replacement Reason Other
*
Please indicate why you are requesting a new badge.
Employee Dept--Title Change Information
New Department
*
New Title
*
Role Details
Employee Role Specifics
*
Administration
Faculty
Staff
Indicate primary role at Southwestern Michigan College.
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Former SMC Student or Employee?
*
Yes
No
Unknown
Has the badge recipient ever previously attended or worked at SMC?
Former Name
Enter former or maiden name badge recipient had while attending Southwestern Michigan College, if different than legal name provided above.
Emergency Personnel Employment Status
*
Active
Reserve
Retired
Emergency Personnel Title
*
Contractor Company Name
*
Please enter the name of the badge recipient's business in the space provided above.
Contractor Title
*
Please enter the badge recipient's title in the field provided above.
Employee Spouse Membership Information
Employee Name
*
Please provide the name of the employee who is the spouse of the applicant.
Housing Resident Information
Housing Resident
*
Yes
No
Residence Hall
*
Not Assigned
Jerdon Hall
McKenzie Hall
White Hall
If the student have been assigned to a room in student housing building, please select the building from the list above or select
Not Assigned
.
Driver's License or Other Government Issued ID
License No.
*
Issuing State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Expiration Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2020
2021
2022
2023
2024
2025
2026
2027
Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Phone
*
Emergency Contact Phone, part 1
-
Emergency Contact Phone, part 2
-
Emergency Contact Phone, part 3
Relationship to Contact
*
Home Address/Phone Information
Street Address
*
City
*
State
*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
*
Phone Number
*
Phone Number, part 1
-
Phone Number, part 2
-
Phone Number, part 3
Comments Questions
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