Registration Form



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Registration Form

To register for library privileges as a faculty research assistant, print out this page, complete both sections of the form, and bring it to the circulation desk in Neilson Library.

Overdue, Hold, and Recall Notices should be sent to:	Proxy's address
	Faculty's address

To be completed by the faculty/staff: (please print legibly)

Faculty/Staff Name:_________________________________ Ext:_____________

Campus Address:__________________________ E-Mail:_____________________

The student is working for me from ____/____/____ through ____/____/____.

1. The student named below is authorized to borrow materials for me from the Five Colleges and through Interlibrary Loan.
2. At the end date noted above, all Smith materials checked out on this card will be transferred to my library record. I will receive and review a list of these items.

Faculty/Staff Signature:_______________________________ Date:__________

To be completed by the student/proxy: (please print legibly)

Student Name:_______________________________________ Ext:____________

Campus Address:_______________________________E-Mail:_________________

1. This card is for borrowing materials solely for the faculty or staff member who submitted this request.
2. Items for your personal use cannot be charged to this card.
3. Never check out materials for the faculty member using your student ID. Use only this proxy card.
4. Borrowing privileges will be revoked if this card is abused.

Student Signature:_____________________________________DATE:____________

OFFICE USE ONLY

DATE REC'D _____ INPUT BY_____ON___/___/___BARCODE_____________________

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Last Updated: November 20, 2006