University of Connecticut Health Center Library
Proxy Registration Form
for
UConn Faculty at Other Campuses


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


Patron Name: *

E-mail Address: *

Campus Information

UConn School or Department*

Contact Person in Department: * (This person will be contacted to verify your position as a UConn faculty member.)

Contact Person Phone Number: *

Campus Address - UBOX:

Campus Telephone Number: *

Residence Information

Street Address: *

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 UConn community.

Send questions to Circulation Department at circ@uchc.edu