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Van Pelt Library
Faculty Proxy Borrower Registration
print this form, complete it and bring to library
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Date ___________________________
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Faculty Information
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Name:
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PENNcard Number (10 digits):
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Department:
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Campus Address:
Building Code:
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Campus Phone:
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Campus E-Mail:
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Faculty Member's Signature:
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By signing here, I agree to be responsible for materials
borrowed in my name by the proxy borrower named below.
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Proxy Borrower Information
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PENNcard Number (10 digits):
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Address:
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Phone:
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E-Mail:
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Proxy Borrower's Signature:
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Expiration Date:
(maximum 1 year except spouse/partner; 5/31 is the default date)
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Note: the faculty member's record and the proxy borrower's record must both be clear before the proxy relationship will be established. Items checked out by the proxy borrower for the faculty member are immediately charged to the faculty member's record.
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DM
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DESK
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Initials ______ Date:_______________
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Initials ______ Date_______________
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