Van Pelt Library
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| Print this form and bring to library |
Faculty Information |
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| 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 |
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| Name: | |
| PENNcard Number (10 digits): | |
| Address: | |
| Phone: | |
| E-Mail: | |
| Proxy Borrower's Signature: | |
| Expiration Date: | |
| DM | DESK |
| Initials ______ Date:_______________ | Initials ______ Date:_______________ |