University of Connecticut Health Center Library
Proxy Registration Form
for
Affiliated, Community Faculty & Community Researcher


Please provide the following information in order to apply for UCHC library borrowing and electronic library access privileges as a community faculty member. If you prefer, you may submit your information via e-mail.


Patron Name: *

E-mail Address: *

UCHC Department Affiliation Information

UCHC Appointment Letter Expiration Date:

UCHC Department or CICATS:

Work Information

Practice Name/Organization Name:

Street Address:

City: State ZIP code

Work Phone No.: *

Residence Information

Street Address: * Apt. No.

City: * State: * ZIP code: *

Home Phone No. : *

* I accept the UConn Health Center Library Terms of Use

The fields with "*" are required fields.

The information required in this application is necessary in order to comply with electronic database licensing requirements and to limit library borrowing privileges to those who are part of the UCHC community.

Send questions to Circulation Department at circ@uchc.edu