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Van Pelt Library
Faculty Proxy Borrower Registration
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Print this form and bring to library |
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: |
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Building Code: |
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Campus Phone: |
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Campus E-Mail: |
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Faculty'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. |
Proxy Borrower Information
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Name: |
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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: |
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DM |
DESK |
Initials ______ Date:_______________ |
Initials ______ Date:_______________ |