Name - Enter the last name, first name, and middle initial of the individual receiving the id+ card
PSU ID# - The individual's PSU ID number must be listed. If a PSU ID number is not already on file for the individual, it is the hiring/sponsoring department's responsibility to assign a new PSU ID number
Campus Address - Enter the campus address of the individual receiving the id+ card
Campus Telephone - Enter the campus telephone number including the area code
College/Admin - Enter the College/Administrative area
Select one of 10 appointment types
End Date - Please indicate when the appointment or affiliation with the University is expected to terminate. Cardholder will not be eligible to receive a replacement card beyond this date. Eligibility end dates can be revised and extended by faxing a revised copy of this form to (814)-865-2929
Signature Line - After the form is completed, the Human Resources (HR) Representative must provide either a hand-written signature or provide their digital ID
Printed Name - Enter the name and title of the HR Representative
Department Name - Enter the Department Name of the HR Representative
Telephone number - Enter the telephone number, including the area code, of the HR Representative
Email - Enter the email address of the HR Representative
