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Proxy Borrower: Home

Van Pelt Library
Faculty Proxy Borrower Registration
Print this form and bring to library

Faculty Information
Name:  
PENNcard Number (10 digits):  
Department:  
Campus Address:  
Building Code:  
Campus Phone:  
Campus E-Mail:  
 
Faculty's Signature:  
By signing here, I agree to be responsible for materials borrowed in my name by the proxy borrower named below.

Proxy Borrower Information
Name:  
PENNcard Number (10 digits):  
Address:  
Phone:  
E-Mail:  
 
Proxy Borrower's Signature:  
Expiration Date:  
DM DESK
Initials ______ Date:_______________ Initials ______ Date:_______________