Emergency Identification
Revoking Privileges

This form is used to delete (revoke) 5 or fewer employees' privileges to the emergency ID. Please do not submit this form repeatedly to delete/revoke more than 5 names. If you need to delete/revoke more than 5 employees click one of the other buttons after using your browser's Back button.

In the first section you must supply a complete registration. Failure to provide the required information will result in an error. You nned to provide a complete registration only if your department is not registered. If you need to make a change in your department's registration information, go back to the previous form and select Update Department Information either now or after you complete this form.

Note: All fields from here to next line across the screen are REQUIRED!

Department name

Contact name
Address (field will scroll if it's long)
Contact's telephone
Contact's email
NAMES TO ADD TO DATABASE


Last name
First name
Last 4 digits of SSN

Last name
First name
Last 4 digits of SSN

Last name
First name
Last 4 digits of SSN

Last name
First name
Last 4 digits of SSN

Last name
First name
Last 4 digits of SSN

   
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Indiana University
Office of Risk Management
400 E. 7th Street Room 705, Bloomington, IN 47405
812-855-9758 FAX 812-855-9320
A division of the Office of the Vice President for Administration, Chief Administrative Officer

Last updated: 20-Mar-2003
Comments: Webmaster
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