Patron Name: *

UCHC Course name/number: *

Instructor's name: *
(The instructor will be contacted to verify your registration in this course)
Instructor's UCHC phone number:

Home Address: *

Apt. No.

City: *

State: *

ZIP code: *

Home Phone No. : *

Home E-mail Address:

Work Address:

City:

State:

ZIP code:

Work Phone No.: *

Work E-mail Address:

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.