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Badge Request
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Badge Holder Request Form

  • Please use this request for users who are not onboarded through HRO
  • All fields marked with asterisk (*) are required.
  • The badge form template can be downloaded here
  • Please enter the form details, upload the picture and click Save. A notification will be sent to your supervisor to complete the badge review and submit to Safety.
  • Once you submit the form, your supervisor will be notified to complete the badge review and submit to Safety.
Personal Information
Email
First Name
MiddleName
Last Name
Preferred Phone
Other Type
Funding Source(s):
Working Status:
Type of Work:
Title:
Work Location:

Please select work location

Other Location
Department:
Expiration date, if any:
Supervisor Name
Supervisor Email
NYSPI ID Photo

Please review the instructions here before uploading your picture for badge

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Attestation
Are you submitting on behalf of someone?

Note: Please select the checkbox below to attest when you complete filling the form. Once you certify, your name will be used in place of your signature for this application.

Signature:
Date:
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