Employee ID Tag Request Employee ID Tag Request "*" indicates required fields EMPLOYEE INFOMATIONLegal Name* First Name Middle Name Last Name (as it appears on your SIN card)SHIPPING CONTACT & ADDRESS INFORMATION(please complete in full to avoid delivery delays & returned mail)Contact Name* IERHA Site Name* IERHA Site Address TAG INFORMATIONTag request for:* New Employee Lost ID Damaged Id New Position Badge type:* Clip Lanyard Lanyard or Clips are provided for NEW & LOST IDs, or if they are damaged A non-refundable $20 fee. processed via payroll deduction for replacing LOST IDs Damaged IDs must be returned to ID Badge Requests at: Corporate Office (please include this form) Old IDs must be returned to Badge Requests at: Corporate Office (please include this form) Notes:First or Preferred Name* How would you like your name to appear on you IDPosition* DO NOT use abbreviations for PositionShared Health Employee ID # Attatch an image: please make sure that the image has a plain background, and it displays your shoulders and above.*Accepted file types: jpeg, jpg, png, bmp, gif, Max. file size: 10 MB.PhoneThis field is for validation purposes and should be left unchanged.
